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SURGERY  AND  DISEASES 
OF  THE  MOUTH  AND  JAWS 


SUMGERY  AND  DISEASES 


OP  THE 


MOUTH    AND    JAWS 


A  PRACTICAL  TREATISE  ON  THE  SURGERY 

AND  DISEASES  OF  THE  MOUTH  AND 

ALLIED  STRUCTURES 


VILRAY  PAPIN  BLAIR,  A  M.,  M.  P.,  P.  A.  C.  S. 

PROFESSOR  OF  ORAX  SURGERY  IN  THE  WASHINGTON  UNIVERSITY  DENTAL 

SCHOOL,  AND  ASSOCIATE  IN  SURGERY  IN  THE  WASHINGTON 

UNIVERSITY  MEDICAL  SCHOOL 


THIRD  EDITION 


REVISED  SO  AS  TO  INCORPORATE  THE  LATEST  WAR  DATA 

CONCERNING  GUNSHOT  INJURIES  OP 

THE  PACE  AND  JAWS 


Compiled  by  the  Section  of  Surgery  of  the  Head,  Subsection  of  Plastic 

and  Oral  Surgery,  Office  of  the  Surgeon-General  of  the 

Army,  Washington,  D.  C. 


With  4-60  Illustrations 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1917 


/ 


Copyright,  1912,  1917,  by  C.  V.  Mosby  Company 


d-'^'l'^ 


Press  of 

C.  v.  Mosby  Company 

St.  Louis 


TO 
THE  FEIENDS 

WHOM  I  HAVE  NEGLECTED  WHILE 
PURSUING  THESE  STUDIES 

THIS  VOLUME  IS  IN  ALL  SINCERITY 
DEDICATED 


PREFACE  TO  THIRD  EDITIOX 


No  surgical  truth  has  received  greater  emphasis  in  this  war  than 
the  necessity  of  correlating  the  skill  and  the  knowledge  of  the  general 
and  the  dental  surgeons  in  the  treatment  of  the  combined  injuries  of 
the   face  and  the  jaw  bones. 

An  eminent  authority  on  military  surgery  said,  after  the  war  of 
1870-71:  "I  should  not  care  to  go  through  another  campaign  without 
having  obtained  competent  technical  assistance  for  those  who  have  sus- 
tained injury  of  the  face  and  fractured  jaw.'' 

The  present  revision  is  mostly  confined  to  the  parts  related  to 
injury  and  sepsis  and  their  treatment,  and  was  done  by  the  Section 
of  Surgery  of  the  Head,  Subsection  of  Plastic  and  Oral  Surgery,  as 
an  expeditious  method  of  giving,  in  a  correlated  form,  the  sum  of  the 
observations  of  the  many  workers  abroad,  to  whose  reports  and  recom- 
mendations, published,  written  and  verbal,  this  section  had  access. 

These  were  put  forth  in  this  form  because,  on  the  one  hand,  time 
did  not  permit  of  a  full  exposition  of  the  subject  in  a  special  manual; 
while  on  the  other,  it  would  be  of  less  utility  and  somewhat  awkward 
to  attempt  to  present  these  observations  while  disregarding  the  well- 
established  principles   upon  which  they  are  based. 

The  subject  of  peridental  infections  has  been  rewritten  by  Dr. 
Arthur  D.  Black,  of  Chicago,  and  read  by  Dr.  Thomas  L.  Gilmer, 
]\Iost  of  the  illustrations  were  furnished  by  Dr.  Black. 

The  chapter  on  local  anesthesia  has  been  revised  by  the  original 
author,  and  that  on  general  anesthesia  by  Dr.  Ellis  Fischel.  Because 
of  insufficient  time,  the  other  chapters,  not  referred  to  in  this  preface, 
were  not  revised. 

The  abstracting  of  the  war  literature  and  much  of  the  assembling 
was  done  by  Captain  Robert  H.  Ivy,  ^Medical  Reserve  Corps,  of  }^Iil- 
waukee ;   while    further   reassembling   and   the   reading   of  proof   was 

IX 


X  PREFACE. 

intrusted  to  Captain  Virgil  Loeb,  Medical  Reserve  Corps,  of  St.  Louis. 
The  author  has  been  collecting  material  for  years  for  a  general 
revision  of  this  book,  and  certain  matters  referring  to  the  repair  of 
defects  have  been  included  in  this  revision,  to  which  have  been  added 
some  recent  observations  on  cancer  of  the  mouth. 

Office  of  the  Surgeon-General  of  the  VILRAY  PAPIN  BLAIR, 

Army,  Washington,  D.  C.  Major,  M.  R.  C,  U.  S.  A.    In  charge 

October  20,  1917.  of  the  Subsection  of  Plastic  and 

Oral  Surgery,  Section  of  Surgery 

of  the  Head. 


PREFACE  TO  SECOND  EDITION 


Advantage  has  been  taken  of  the  opportunity  afforded  by  the 
issuing  of  the  second  edition  to  eliminate  certain  typographical 
errors  and  in  a  few  places  to  reconstruct  the  text.  The  author 
wishes  also  to  avail  himself  of  this  opportunity  to  thank  the  pro- 
fession for  their  kind  reception  of  this  book. 

VILRAY  PAPIN  BLAIR. 

August  1st,  1913. 


PREFACE  TO  FIRST  EDITION 


In  spite  of  all  of  the  special  work  that  has  been  done  in  the  study  of 
the  teeth  and  allied  structures,  the  ordinary  standard  of  surgical  treat- 
ment given  to  diseases  and  deformities  of  the  mouth  does  not  equal  that 
attained  in  other  regions.  This  is  due  largely  to  a  rather  general  lack 
of  reciprocity  of  ideas  and  observations  between  constructive  workers 
in  the  medical,  with  those  of  the  dental  professions. 

It  was  with  the  hope  of  presenting  their  more  pertinent  observations 
and  deductions  in  a  coordinated  scheme  that  the  present  work  was 
undertaken.  This  attempt  has  been  made  possible  by  the  untiring 
efforts  that  the  author's  many  associates  in  the  dental  profession  have 
always  made  to  help  him  solve  cases  that  contained  dental  problems. 

For  the  benefit  of  his  dental  students  certain  chapters  on  surgical 
pathology  and  surgical  principles  have  been  included.  As  hemorrhage 
is  often  a  serious  matter  in  mouth  operations,  this  has  been  considered 
at  some  length. 

Throughout,  the  attempt  has  been  made  to  give  proper  credit  to  the 
originators  of  ideas  presented,  but  this  is  not  always  possible.  Most 
procedures  are  common  property,  their  origin  having  been  lost.  Fur- 
ther, similar  problems  often  evoke  similar  answers,  and  the  same  pro- 
cedure is  often  reinvented  many  times.  Even  when  a  unique  condition 
demands  a  somewhat  radically  new  procedure,  the  deductions  that  seem 
to  warrant  it  are  often  largely  adapted  from  the  observations  and  pro- 
cedures of  others,  though  these  may  have  been  made  and  executed  under 
different  circumstances  and  in  other  regions. 

The  author  is  deeply  indebted  to  Dr.  William  Krenning  for  a  thor- 
ough sifting  of  the  English,  German,  and  French  literature  of  the 
subject.  Among  others,  he  is  also  indebted  to  Drs.  Thomas  Gilmer, 
Hermann  Prinz,  Willard  Bartlett,  John  Kennerly,  B.  E.  Lischer, 
Greenfield  Shider,  William  Coughlin,  William  Mook,  James 
Clemens,  M.  A.  Bliss,  and  Charles  Klenk  for  reading  certain  chap- 

XI 


XII  PREFACE. 

ters,  or  for  other  help  extended,  and  to  many  other  physicians  and 
dentists  for  the  opportunity  of  studying  interesting  cases. 

The  illustrations  have,  with  the  exception  of  bone  lesions,  been 
almost  entirely  confined  to  special  anatomy,  deformities,  and  technique. 
These  have  been  made  directly  from  bones,  dissections,  or  from  patients. 
For  permission  to  reproduce  certain  anatomical  plates  from  Spalteholz, 
Hand  Atlas  of  Anatomy,  the  author  is  indebted  to  J.  B.  Lippincott  and 
Company. 

Most  of  the  skiagrams  presented  were  made  by  Dr.  R.  D.  Carman 
or  by  Dr.  F.  B.  Hall. 

VILRAY  PAPIN  BLAIR. 

St.  Louis,  October,  1912. 


CONTENTS. 


CHAPTER  I. 

PAGE 

Physical  Examination — Anatomical  Consideration 1-27 

Examination — Mouth  Cavity — Floor  of  the  Mouth — Tongue — Palate — 
Fauces  and  Pharynx — Teeth — Gums — Vestibule  of  the  Mouth — Lips — 
Temporomandibular  Joint — Jaws — Muscles  of  Mastication — Salivary 
Glands — Lymph  Nodes. 


CHAPTER  IL 

Inflammations,  Infections,  Tumors,  Cysts 28-41 

Inflammation  —  Infections  —  Suppuration  —  Treatment  of  Infections 
and  Inflammations — Method  of  Preparing  and  Administering  Auto- 
genous Vaccines — Tumors  and  Cysts. 


CHAPTER  III. 

Preparation  of  the  Hands,  Operative  Field,  Instruments,  and  Dress- 
ings         42-45 

Preparation  of  the  Surgeon's  Hands — Preparation  of  the  Operative 
Field — Sterilization  of  Instruments — Sterilization  of  Rubber  Gloves 
— Sterilization  of  Cloths,  Dressings,  Etc. — Sterilization  of  Sutures. 


CHAPTER  IV. 

Hemorrhage.  Shock,  and  Allied  Complications 46-64 

Hemorrhage — Saline  Transfusion — Blood  Transfusion — Shock — Air 
Embolism — Postoperative  Pneumonia — Edema  of  the  Lungs — Sup- 
pression of  Urine — Acetonuria. 


CHAPTER  V. 

Wounds  and  In.turies  of  the  Soft  Parts 65-82 

Wounds — Burns — Sutures — Dressings. 


CHAPTER  VI. 

Injuries  of  the  Teeth  and  Alveolar  Process 83-85 

Mechanical  Abrasion   of  the  Teeth — Loosening  or  Avulsion  of  the 
Teeth — Fracture  of  the  Teeth — Fracture  of  the  Alveolar  Process. 

XIII 


XIV  CONTENTS. 

CHAPTER  VII. 

PAGE 

Fractures  of  the  Upper  Jaw 86-92 

Character  of  the  Injury — Treatment. 


CHAPTER  VIII. 

Fractures  of  the  Lo^\'^R  Jaw 93-130 

Character    of    the    Injury — Treatment — Feeding    During    the    Treat- 
ment of  a  Fracture  of  the  Jaw. 


CHAPTER  IX. 

Treatment  of  Individual  Fractures 131-145 

Fractures  Without  Loss  of  Substance — Time  Required  for  Union — 
Delayed  Union — Malunion — Gunshot  Fractures  of  the  Jaw-Bones. 


CHAPTER  X. 

Dislocation  of  the  Lower  Jaw 146-152 

Kinds  of  Dislocations — Treatment — Unreduced  Dislocations — Chronic 
Dislocations — Subluxation. 


CHAPTER  XI. 

Congenital  Facial  Clefts 153-169 

Morphology — Relation  of  the  Alveolar  Cleft  to  the  Teeth — Clinical 
Types  of  Congenital  Clefts — Theories  of  Failure  of  Cleft  Closure — 
Congenital  Lip  Pits. 


CHAPTER  XII. 

Concenital  Palate  Clefts — Principles  of  Repair  by  Plastic  Flaps  .  170-178 
Anatomical  Considerations — Flaps  made  from  Palate  Tissues — Flaps 
made  from  other  than  Palate  Tissues. 


CHAPTER  XIII. 

Congenital  Clefts  of  the  Palate  and  Lip — Preferable  Age  at  which 

to    Operaje 179-181 

Consideration  of  Various  Ages — Advantages  of  Very  Early  Operation. 


CONTENTS.  XV 

CHAPTER  XIV. 

PAGE 

Congenital  Palate  and  Lip  Clefts — Operations  in  Early  Infancy   .   182-197 
Preparation    for    Operation — Brophy    Operation — Lane    Operation — 
Choice  of  Operation — After-treatment — Mortality. 


CHAPTER  XV. 

Congenital  Palate  Clefts — Plastic  Operations  in  Ordinary  Cases  After 

Early  Infancy 198-216 

Preparation  for  Operation — Position  and  Light — Instruments  and 
Materials — Flap  Sliding  Operation — Retention  Devices — After-treat- 
ment— Postoperative  Hemorrhage — Non-union — Reoperation — Mortal- 
ity— Results. 


CHAPTER  XVI. 

Congenital  Palate  Clefts — Operations  for  Extraordinary  Cases    .    217-226 
Kiister's    Operation — Two-step    Operations — Approximation    of    the 
Maxillae — Repair  by  Flaps  from  Other  than  Palate  Sources. 


CHAPTER  XVII. 

Congenital  Clefts  of  the  Lip  and  Alveolar  Process — Operative  Cor- 
rection         227-241 

Correction  of  Alveolar  Clefts  in  Infants — Correction  of  Single  Alve- 
olar Clefts  at  Later  Periods — Correction  of  Double  Alveolar  Clefts 
at  Later  Periods — Correction  of  Harelip — ^Rose  Operation — Owen 
Operation — Operation  for  Double  Harelip — Correction  of  Deformity 
of  the  Nostril  and  Nose — DifBcult  Respiration  After  a  Lip  Operation 
— After-treatment — Results. 


CHAPTER  XVIII. 

Obturators,  Artificial  Vela,  and  Speech  Training 242-247 

Physiological  Action  of  the  Muscle  Concerned — Obturators  and  Arti- 
ficial Vela — "Cleft  Palate"  Speech — Speech  Training — Postpharyngeal 
Injection  of  Paraffin — Obturators  Versus  Operation. 


CHAPTER  XIX. 

Repair  of  Acquired  Defects  in  the  Lips,  Cheeks,  and  Palate  .  .  248-278 
Varieties  of  Grafts— Transplantation  of  Skin-  or  Mucus-covered 
Flaps — Closure  of  Defects  at  the  Angle  of  the  Mouth  and  Cheek — 
Restoration  of  the  Lower  Lip — Bone  Grafts — Deep  Scars  on  the 
Face — Restoration  of  the  Upper  Lip — Perforations  of  the  Palate — 
After-treatment. 


XVI  CONTENTS. 

CHAPTER  XX. 

PAGE 

Ideal   Occlusion   and  Malocclusion   of   the   Teeth — Irregularities  in 

THE  Growth  and  Relation  of  the  Jaws     .     .     .     .     .     .     .     279-287 

Ideal  Occlusion — Malocclusion — Causes  of  Irregular -Setting  of  Teeth 
— Malrelation  of  the  Dental  Arches  and  of  the  Jaws — Orthodontia  in 
the  Treatment  of  Malrelations  of  the  Jaws — Indications  for  Surgical 
Operation. 


CHAPTER  XXL  ? 

Treatment  of  Deformities  and  Malrelations  of  the  Jaws  .  .  .  288-312 
Deformities  of  the  Maxillae:  Osseous  Obstruction  of  the  Nares — Re- 
traction of  the  Lower  Jaw — Operation  for  Retraction  of  the  I^ower 
Jaw — Obliquity  of  the  Chin — Protrusion  of  the  Lower  Jaw — Irans- 
mucoperiosteal  Operation  for  Protrusion  of  the  Lower  Jaw — Submu- 
coperiosteal  Operation  for  Protrusion  of  the  Lower  Jaw — Babcock's 
Operation  for  Protrusion  of  the  Lower  Jaw — Open  Bite— Operation 
for  Open  Bite — Atypical  Deformities — Preoperative  Considerations — 
After-treatment. 


CHAPTER  XXII. 

Diseases  of  the  Temporomandibular  Joint — Limited  Movement  of  the 

Jaw 313-327 

Diseases  of  the  Temporomandibular  Joint — Hysterical  Closure  of  the 
Jaws — Limitation  Due  to  Reflex  Irritation — Limitation  of  Move- 
ments Following  War  Injuries — Limitations  Due  to  Scar  Bands  or 
Ankylosis — Operative  Treatment  of  Oral  Scar  Bands — Operation  by 
Flap  Transplantation — Operations  for  Ankylosis  of  the  Jaw 


CHAPTER  XXIII. 

Fkactukks  and  Deformities  of  the  External  Nose     .     .     .     .     .     .     328-339 

Treatment  of  Fractures  of  the  Nose. 


CHAPTER  XXIV. 

Extraction  of  Teeth 340-347 

Removal  of  the  Individual  Teeth — Impacted  Teeth. 


CHAPTER  XXV. 

I.\FECTio.\s  A.\D  Inflammations  of  tiif  Moittii 348-370 

Stomatitis — Gangrene     (Slough) — Noma     (Cancrum    Oris) — Specific 
Infections — Parasites  of  the  Mouth. 


CONTENTS.  XVII 

CHAPTER  XXVI. 

PAGE 

Infections  of  the  Teeth,  Peridental  Tissues  and  Maxillary  Bones  .  371-391 
Alveolar   Abscess — Diseases    of   the    Gingivae   and    Peridental    Mem- 
brane— Osteitis  or  Inflammation  of  the  Bone — Necrosis — Specific  In- 
fections  of   Bone — Atrophy — Hypertrophy — Tumors    of   Bone — Leon- 
tiasis  Ossea. 


CHAPTER  XXVII. 

Treatment  of   Infections   of  the   Teeth,   Peridental  Membranes,   and 

Maxillary  Bones 392-408 

Acute  Alveolar  Abscess — Chronic  Alveolar  Abscess — Necrosis — 
Chronic  Bone  Abscess  —  Acute  Ulcerous  Gingivitis  —  Gingivitis 
Caused  by  Deposits  of  Salivary  Calculus — Gingivitis  Caused  by  De- 
posits of  Serumal  Calculus — Gingivitis  Due  to  Injuries — Chronic 
Suppurative  Pericementitis — Specific  Infections. 


CHAPTER  XXVIIL 

Septic  Infections  of  the  Floor  of  the  Mouth  and  Neck     ....     409-417 
Acute  Adenitis — Acute  Cellulitis— Chronic  Adenitis — Chronic  Cellu- 
litis— Treatment  of  Acute  Adenitis — Treatment  of  Acute  Cellulitis — 
Treatment  of  Chronic  Adenitis — Treatment  of  Chronic  Cellulitis — 
Phlegmonous  Stomatitis — Abscess  of  the  Tongue. 


CHAPTER  XXIX. 

Diseases  of  the  Maxillary  Sinus 418-426 

Antral  Infection — Cysts  of  the  Antrum^ — Tumors  of  the  Antrum. 


CHAPTER  XXX. 

Tumors  of  the  Mouth  and  Jaw-Bones 427-453 

Hypertrophy  of  the  Gums  —  Mucous  Cysts  —  Epulis  —  Lipoma  — 
Fibroma — Chondroma — Osteoma  —  Myxoma — Odontoma — Supernum- 
erary Teeth — Dental  Cysts  —  Sarcoma — Myeloma — Endothelioma — 
Multilocular  Cystic  Tumors — Carcinoma — Retromaxillary  Tumors. 


CHAPTER  XXXI. 

Excisions  and  Temporary  Resections  of  the  Jaw-Bones     ....     454-467 
Resections  and  Excisions  of  the  Maxilla — Osteoplastic  Resections — 
Resection  and  Excision  of  the  Mandible — Prevention  of  Deformity. 


XVIII  CONTENTS. 

CHAPTER  XXXIT. 

PAGE 

Diseases  ajs^d  Tumors  of  the  Lip 468-473 

Injuries — Scars — Lip  Cracks  or  Cliaps— Simple  Hypertrophy— Macro- 
clieilia — Furuncle — Phlegmon — Gangrene — Herpes — Perleche — Tuber- 
culosis of  the  Lips— Syphilis — Cysts— Hemangioma — Endothelioma— 
Warts  and  Papillomata. 

CHAPTER  XXXIII. 

Cancer  of  the  Lip 474-483 

Diagnosis — Treatment — Prognosis. 

CHAPTER  XXXIV. 

Tumors  and  Cysts  of  the  Floor  of  the  Mouth 484-491 

Obstruction  Cysts  of  the  Mucous  Glands — Ranula — Dermoid  Cysts — 
Benign  Tumors — Malignant  Tumors. 

CHAPTER  XXXV. 

Affections  of  the  Salivary  Glands  and  Their  Ducts 492-523 

Inflammation  of  the  Larger  Ducts — Epidemic  Parotitis — Acute  Sup- 
purative Inflammation  of  the  Submaxillary  and  Sublingual  Glands 
in  Young  Infants — Secondary  Infections  and  Septic  Parotitis — 
Chronic  Inflammation — Hypertrophy  (Mikulicz's  Disease) — Speciflc 
Infection  of  the  Salivary  Glands — Obstruction  of  the  Ducts  of  the 
Salivary  Glands — Cysts — Foreign  Bodies  and  Stones  in  the  Ducts  and 
Glands — Wounds  of  the  Salivary  Glands  and  Ducts — Salivary  Fis- 
tula— Tumors  of  the  Salivary  Glands. 

CHAPTER  XXXVI. 

Congenital  Affections  and  Inflammations  of  the  Tongue     .     .     .     524-536 
Congenital    Deformities — Nodules — Indentations — Fissures — Ulcers — 
Inflammations — Raw  Tongue — Erythema  Migrans  Linguae — Chronic 
Superficial   Glossitis— Glossodynia   Exfoliativa — Tuberculosis   of  the 
Tongue — Syphilis  of  the  Tongue. 

CHAPTER  XXXVII. 

Tumors  of  the  Tongue 537-550 

Lymphangiomatous  Macroglossia— Simple  Muscular  Macroglossia — 
Tumors  of  the  Blood  Vessels— Cartilaginous  Tumors— Lipoma — 
Fibroma— Keloid— Tumors  and  Cysts  of  the  Thyroglossal  Tract— 
Papillomata,  Warts— Sarcoma. 


CONTENTS.  XIX 

CHAPTER  XXXVIII. 

PAGE 

Cancer  of  the  Tongue 551-592 

Position — Etiology  and  Predisposition — Early  Diagnosis — Responsi- 
bility of  Medical  Practitioners  and  Dentists  in  Regard  to  the  Recog- 
nition of  the  Early  Manifestations  of  Cancer — Early  Types  of  Cancer 
— Early  Clinical  Characteristics — Clinical  Stages  of  Carcinoma  of  the 
Tongue — Mid-period  of  Carcinoma  of  the  Tongue — Pinal  Stage  of 
Carcinoma  of  the  Tongue — Diagnosis — Differentiation  between  Oper- 
able and  Non-operable  Carcinomata — Prognosis  of  Carcinoma  of  the 
Tongue — Treatment  of  Carcinoma  of  the  Tongue — Operation  for  the 
Removal  of  the  Tongue — -Intraoral  Operation — V-shaped  Operation — 
Excision  of  One  Half  of  the  Body — Bilateral  Excision — Resection  of 
the  Tongue  at  the  Root — Kocher's  Operation- — After-treatment. 


CHAPTER  XXXIX. 

Tuberculous  and  Malignant  Diseases  of  the  Cervical  Lymphatics   .   593-605 
Tuberculous   Adentis — Secondary   Carcinoma    of   the    Cervical   Lym- 
phatics. 


CHAPTER  XL. 

Congenital  Malformations,  Injuries,  and  Diseases  of  the  Pharynx  .  606-618 
Anatomical     Considerations  —  Congenital     Malformations     of     the 
Pharynx — Injuries  of  the  Pharynx — Acute  Infections — Adhesions  of 
the    Velum    and    Fauces    and    Pharyngeal    Wall — Stricture    of    the 
Pharynx. 


CHAPTER  XLI. 

Tumors  of  the  Velum,  Tonsils,  and  Pharynx 619-628 

Teratomata  —  Benign  Tumors  —  Palate  Adenoma  —  Nasopharyngeal 
Polypus  or  Nasopharyngeal  Fibroma — Retropharyngeal  Goiter — 
Malignant  Tumors  of  the  Pharynx — Pharyngotomy. 


CHAPTER  XLII. 

Ligation  and  Temporary  Constriction  of  the  Arteries 629-634 

Coronary  Arteries — Temporal  Artery — Facial  Artery — Lingual  Artery 
— External  Carotid  Artery^ — Common  Carotid  Artery. 


CHAPTER  XLIII. 

Motor  Derangement 634-643 

Paralytic  Affections — Spasmodic  Affections. 


XX  •  CONTENTS. 

CHAPTER  XLIV. 

PAGE 

Tic  Douloureux  and  Sphenopalatine  Neuralgia 644-674 

Fifth  Cranial  Nerve — Tic  Douloureux:   Major  Neuralgia  of  the  Fifth 
Cranial  Nerve — Sphenopalatine  Neuralgia — Treatment. 


CHAPTER  XLV. 

Local  Anesthesia 675-690 

Means  of  Producing  Local  Anesthesia — Hypodermic  Armamentarium 
— Technique  of  Injection — Local  Anesthesia  for  Operations  About  the 
Mouth, 


CHAPTER  XLVI. 

General  Anesthesia 691-696 

Chloroform  —  Ether  —  Intratracheal     or     Insufflation     Anesthesia  — 
Nitrous  Oxid — Infiltration  Anesthesia. 


APPENDIX. 

Appendix 697 


ILLUSTRATIONS. 


FIGURE  PAGE 

1.  Coronal  section  through  the  face 3 

2.  Muscular  floor  of  the  mouth 4 

3.  Sublingual  mucous   surface ...  5 

4.  Sublingual  structures 6 

5.  Sagittal  section  through  the  face 8 

6.  Dorsum  of  the  tongue 9 

7.  Submucous  palate  structures 13 

8.  Position  of  the  teeth 15 

9.  Myocardiogram  in  air  embolism 59 

10.  Blood  pressure  tracings  in  air  embolism 60 

11.  Blood  pressure  tracings  in  air  embolism 61 

12.  Blood  pressure  tracings  in  air  embolism 61 

13.  Injury  from   shell  fragment 67 

14.  Interrupted  suture,  defective 79 

15.  Interrupted  suture,  defective 79 

16.  Interrupted  suture,  effective 79 

17.  Eelation  of  suture  to  wound 79 

18.  Deep  suture 79 

19.  Modified  Lane  suture 79 

20.  Figure-of-eight  suture        79 

21.  Fracture  of  the  maxilla        89 

22.  Fracture  of  the  maxillae 91 

23.  Splint  for  comminuted  fracture  of  the  upper  jaw 92 

24.  Direction  of  pull  of  the  floor  muscles 94 

25.  Diagram  of  horizontal  displacement  in  fracture  at  first  molar     .  94 

26.  Diagram    of    horizontal    displacement    in    double    fracture    at    the 

cuspids 94 

27.  Diagram  of  horizontal  displacement  in  fi-acture  near  the  angle     .  94 

28.  Diagram  of  the  pull  of  the  floor  muscles 95 

29.  Diagram  of  vertical  displacement  in  fracture  in  front  of  the  canine  95 

30.  Diagram  of  vertical  displacement  in  double  fracture  at  the  canine  95 

31.  Diagram  of  lack  of  vertical  displacement  in  double  fracture  at  the 

bicuspids 95 

32.  Diagram  of  the  pull  of  the  muscles  of  mastication 96 

33.  Diagram  of  vertical  displacement  in  fracture  behind  the  molars     .  97 

34.  X-ray  of  fracture  of  the  ramus 98 

35.  Angle  fracture  bands 100 

36.  Gilmer's  method  of  wiring  the  teeth 100 

37.  Gilmer's   wires   in   position 101 

38.  X-ray  of  silver  wire  passed  around  symphysis 103 

39.  Gilmer's  wires  protected  by  gum 104 

XXI 


XXII  ILLUSTRATIONS. 

FIGURE  PAGE 

40.  Diagram  of  method  of  wiring  the  body  of  the  jaw 105 

41.  X-ray  of  a  wired  fracture 106 

42.  Hammond  splint 107 

43.  Splint  for  fracture  and  loss  of  bone  in  incisor  region 108 

44.  Inclined  plane  of  splint 108 

45.  Plaster  cast  in  fracture  of  the  jaw 109 

46.  Sawed  plaster  cast  of  the  fractured  jaw 109 

47.  Plaster  cast  reconstructed,  in  fracture  of  the  jaw 109 

48.  49.  Two  views  of  fractured  mandible  in  malposition Ill 

50.  Guilford's  articulator Ill 

51.  Face-bow  in  position  in  articulator 112 

52.  Model  placed  in  articulator 112 

53.  Finished  splint  in  place  on  model 113 

54.  Gunning  splint 114 

55.  Metal  gunning  splint    (Kelly-Supplee)    for  emergency   fixation   of 

fractures  of  the  jaw  bones 115 

56.  Impression  tray  converted  into  a  Kingsley  splint 115 

57.  Hullihan  splint 116 

58.  Gilmer  posterior  band  splint 116 

59.  Modified  Gunning  splint 117 

60.  Band  and  wire  splint 118 

61.  Metallic  band  splint  to  bridge  defect 119 

62.  Sectional  metal  jacket  and  wire  splint 120 

63.  64.  Sectional  vulcanite  splints  with  jack-screws  for  slow  separation 

of  fragments 121 

65.  Swaged  metal  jacket  splint  with  hooks  and  ligature  wire     .     .     .  121 

66.  Metal  jacket  splints  with  inclined  planes 122 

67.  Sectional  removable  vulcanite  prosthesis / .     .     .     .  123 

68.  Permanent  chin  prosthesis 124 

69.  70.  Illustrations    emphasizing  the   danger   of   dressing   the   mouth 

open 125 

71.  Induration  surrounding  fracture 127 

72,  73.  Improperly  set  fracture 132 

74.  X-ray  of  displacement  of  the  ramus 133 

75.  Lower  bar  and  saddle  splint 133 

76.  X-ray  of  displacement  of  the  ramus 134 

77.  Facial  support 140 

78.  Facial  support 141 

79.  Modified  Barton  bandage 144 

80.  Ligaments  of  the  temporomandibular  joint 147 

81.  Section  through  the  temporomandibular  joint 148 

82.  Head  of  a  fetus  in  the  fifth  week 153 

83.  Head  of  a  fetus  in  the  seventh  week 153 

84.  Schematic  diagram  of  facial  clefts 154 

85.  Diagram  of  oblique  facial  cleft 155 

86.  Oblique  facial  cleft 155 

87.  Diagram  of  ordinary  harelip 156 

88.  Single  harelip 156 

89.  Median  harelip 156 

90.  Absence  of  the  intermaxillary  process 157 


ILLUSTRATIONS.  xxiil 

FIGUKE  PAGE 

91.  Absence  of  the  intermaxillary  process 157 

92.  Diagram  of  macrostomia 158 

93.  Partial  macrostomia 158 

94.  Macrostomia 158 

95.  Diagram  of  cleft  of  lower  lip 159 

96.  Diagram  of  the  palate  in  the  sixth  fetal  week 159 

97.  Diagram  of  complete  cleft  palate 160 

98a. Pendulous  tooth  in  alveolar  cleft 161 

98b. Protruding  tooth  buds  in  alveolar  cleft 161 

99.  Midline  cleft 161 

100.  Incomplete  double  harelip "^  .     .     .  163 

101.  Complete  double  harelip 163 

102.  Skull  with  complete  single  palate  cleft 164 

103.  Skull  with  incomplete  double  palate  cleft 165 

104.  Incomplete   harelip       168 

105.  Lip  pits 169 

106.  Essential  palate  muscles       171 

107.  Diagram  of  double  cleft  of  the  palate 172 

108.  Diagram  of  single  cleft  of  the  palate 172 

109.  Diagram  showing  the  velum  detached  from  the  palate     ....  173 

110.  Intranasal  palate  flaps 174 

111.  Diagram  of  the  efficiency  of  palate  flaps 175 

112.  Diagram  of  cleft  closed  with  the  flap  from  the  neck 177 

113.  Single  complete  cleft  in  an  infant 180 

114.  Single  complete  cleft  in  an  infant,  repaired 180 

115.  Closure  of  the  bony  cleft  in  early  infancy,  first  step 183 

116.  Closure  of  the  bony  cleft  in  early  infancy,  second  step     ....  184 

117.  Closure  of  the  bony  cleft  in  early  infancy,  third  step 185 

118.  Closure  of  the  bony  cleft  in  early  infancy,  wires  traversing  the 

maxillae 186 

119.  Closure  of  the  bony  cleft  in  early  infancy,  completed  operation  .     .  186 

120.  %-circle  needle 186 

121.  Coronal  section  of  an  infant's  face 187 

122.  Relation  of  an  infant's  jaws  in  cleft  of  the  palate 188 

123.  Growth  of  the  palate       188 

124.  Diagram  of  needle  traversing  the  maxilla 189 

125.  Brophy  palate  needle 189 

126.  Diagram  of  crushing  forceps  applied  to  maxillae 190 

127.  Knife  for  cutting  the  maxilla 190 

128.  Cast  of  single  cleft  of  the  palate  in  an  infant 191 

129.  Cast  of  single  cleft  of  the  palate  in  an  infant,  repaired     ....  192 

130.  Diagram  of  mucoperiosteal  flaps 192 

131.  Incision  for  Lane  operation  for  a  single  palate  cleft 192 

132.  Lane  operation  for  a  single  palate  cleft,  completed 192 

133.  Lane  operation  for  a  velum  cleft 193 

134.  Incisions  for  Lane  operation  for  a  cleft  in  the  posterior  part  of  the 

hard  palate 193 

135.  Lane  operation  for  a  cleft  in  the  posterior  part  of  a  hard  palate, 

completed 193 

136.  Incision  for  Lane  operation  for  a  complete  double  palate  cleft     .     .  194 


XXIV  ILLUSTRATIONS. 

FIGUEE  PAGE 

137.  Lane  operation  for  a  complete  double  palate  cleft,  completed     .     .  194 

138.  Robert's  modification  of  Hammond  palate  clamp 197 

139.  Diagram  of  the  amount  of  tissue  available  for  a  palate  flap     .     .  198 

140.  Lane  gag 200 

141.  Owen's  modification  of  Smith  gag 201 

142.  Palate  tenaculum  constructed  from  artery  forceps 202 

143.  Tonsil  scissors 202 

144.  Brophy  elevators 204 

145.  Bartlett  elevator 204 

146.  Application  of  Bartlett  elevator 205 

147.  Shepherd's  crook  needle        206 

148.  Insertion  of  the  shepherd's  crook  needle 206 

149.  McCurdy's  method  of  using  the  shepherd's  crook  needle,  first  step  .  206 

150.  McCurdy's  method  of  using  the  shepherd's  crook  needle,  third  step  207 

151.  Vertical  mattress  suture 207 

152.  Freeing  the  velum  from  hard  palate 207 

153.  Paring  the  left  border  of  a  palate  cleft 209 

154.  Paring  the  right  border  of  a  palate  cleft 209 

155.  First  insertion  of  the  needle 211 

156.  Last  insertion  of  the  needle  of  the  first  suture  of  the  palate  cleft  .  211 

157.  Vertical  mattress  suture  in  the  mucoperiosteal  flap 212 

158.  Vertical  mattress  suture  in  the  velum 212 

159.  Suturing  the  velum ' 212 

160.  Suturing  the  mucoperiosteal  flaps 212 

161.  Stay  sutures  in  position 213 

162.  Lead  plates  in  position 214 

163.  Incisions  for  modified  Kiister  operation         218 

164.  Modified  Kiister  operation,  completed 218 

165.  Palate  cleft  of  extraordinary  width 219 

166.  Cleft  narrowed  by  packing  under  flaps 219 

167.  Cast  showing  the  lateral  incisions  in  a  wide  cleft 220 

168.  Cast  showing  the  lateral  incisions  in  a  wide  cleft 220 

169.  Cast  showing  the  result  of  operation  on  a  wide  cleft 220 

170.  Cast    showing    the    defect    resulting    from    sloughing    at   previous 

operations 221 

171.  Cast  showing  the   operative    results 221 

172.  Cast  showing  wide  cleft  with  protruding  intermaxillary  process  .     .  222 

173.  Cast  showing  cleft  narrowed,  and  intermaxillary  process  brought 

back  by  orthodontic  apparatus 222 

174.  Cast  showing  final  operative  results 222 

175.  Incisions  for  repairing  cleft  with  buccal  fiaps 223 

176.  Cleft  repaired  with  buccal  flaps 223 

177.  Cast  showing  wide   defect  resulting  from   sloughing   at   previous 

operations 225 

178.  Cast  showing  wide  defect  repaired  with  neck  flap 225 

179.  Permanent  gag  protecting  the  neck  flap  from  the  teeth     ....  226 

180.  Scar  resulting  from  turning  a  neck  flap  into  the  mouth     ....  226 

181.  Displacement  of  alveolar  process  in  a  case  of  alveolar  cleft     .     .     .  227 

182.  Method  of  closing  a  wide  alveolar  cleft 228 

183.  Alveolar  cleft  closed  by  operation 228 


ILLUSTRATIONS.  xxv 

I'lGURE  ,  PAGE 

184.  Line  of  incision  for  replacing  intermaxillary  process 229 

185.  Protruding  intermaxillary  process  in  a  double  harelip,  with  single 

alveolar  cleft 230 

186.  Protrudng  intermaxillary  process  in  a  double  harelip,  with  com- 

plete double  cleft  at  the  palate 230 

187.  Retraction  of  the  tip  of  the  nose  after  the  repair  of  the  double 

harelip 230 

188.  Constriction  of  nostril  after  a  harelip     . 231 

189.  Temporary  compression  of  blood  vessels,  while  repairing  a  harelip  232 

190.  Incisions  for  a  Rose  operation  for  an  incomplete  lip  cleft     .     .     .  233 

191.  Incisions  for  a  Rose  operation  for  a  complete  single  cleft     .     .     .  233 

192.  Method  of  approximating  the  cleft  borders  for  a  suture,  after  a 

Rose  operation 233 

193.  Incision  for  a  Rose  operation  for  incomplete  double  harelip     .     .     .  233 

194.  Completed  Rose  operation  for  double  harelip 233 

195.  Cast  showing  result  of  an  unsuccessful  harelip  operation     ....  234 

196.  Cast  showing  the  result  of  operation  after  an  unsuccessful  harelip 

operation 234 

197.  Incisions  for  the  Owen  operation  for  single  harelip 235 

198.  Suturing  of  the  vertical  cut  in  an  Owen  operation     ......  235 

199.  Suturing  of  the  transverse  cut  in  an  Owen  operation 235 

200.  Incisions  for  an  operation  for  a  complete  double  harelip     ....  235 

201.  Completed  operation  for  double  harelip 235 

202.  Stay  suture  and  lead  plates,  after  a  harelip  operation     ....  237 

203.  The  cutting  of  a  displaced  nasal  septum 238 

204.  Replaced  nasal  septum  anchored  to  a  bicuspid  tooth 238 

205.  Replaced  nasal  bones  anchored  to  a  molar  tooth 239 

206.  Breathing  tube 240 

207.  Diagram  showing  closure  of  nasopharynx  by  the  velum  and  superior 

pharyngeal  constrictor       243 

208.  Nasopharynx  open 243 

209.  Constrictor  action  of  the  superior  pharyngeal  constrictor     .     .     .  244 

210.  Obturator  for  cleft  of  the  velum 244 

211.  Obturator  for  cleft  of  the  velum       . 245 

212.  Nasal  pharyngeal  obturator  to  supplement  a  short  velum     .     .     .  245 

213.  Diagram  of  the  seventh  nerve 251 

214.  Transplantation  of  forehead  flap  with  anterior  temporal  artery  to 

fill  defect  of  cheek 253 

215.  Showing  defect  with  skin  borders  drawn  by  scar  contraction     .     .  254 

216.  Transplantation  of  forehead  flap  to  fill  defect  in  cheek 254 

217.  Transplantation  of  forehead  flap  to  fill  defect  in  cheek 254 

218.  Neck  flap   sloughing 255 

219.  Incision  for  repaii'ing  a  cheek  defect  by  sliding  flaps 256 

220.  Repair  of  a  cheek  defect  with  a  neck  flap 257 

221.  Repair  of  a  cheek  defect  with  a  neck  flap,  second  step 257 

222.  Repair  of  a  cheek  defect  with  a  neck  flap 258 

223.  Serre  operation  for  replacing  the  angle  of  the  mouth 258 

224.  Result  of  a  Burow-Stewart  operation 259 

225.  Ability  to  elevate  the  upper  lip  after  a  Burow-Stewart  operation     .  260 

226.  Repair  of  defect  of  cheek  with  flap  from  neck 261 


XXVI  ILLUSTRyVTIONS. 

FIGURE  PAGE 

227.  Burow-Stewart  operation  for  restoring  the  lower  lip 262 

228.  The  V-shaped  excision  of  a  small  lip  tumor 262 

229.  Eesult  of  a  V-shaped  excision  from  the  lip 262 

230.  Excision  of  half  the  lower  lip  in  the  corner  of  the  month    ....  262 

231.  Result  of  excision  shown  in  the  preceding  figure 262 

232.  Excision  of  the  corner  of  the  month 263 

233.  Eesult  after  the  excision  shown  in  the  preceding  figure     ....  263 

234.  Excision  of  the  lower  lip  and  chin  to  be  repaired  with  neck  flaps     .  263 

235.  Result  of  the  excision  shown  in  the  preceding  figure 263 

236.  Diagrammatic   representation  of  the   right  costal    cartilage   from 

which  cartilaginous  grafts  may  be  obtained 265 

237.  Transplantation   of  bone  to   repair  bony   defect   of   jaw   at   chin, 

implanted  piece  of  rib  in  position 268 

238.  Same  as  Fig.  237.     Raising  the  flap  at  second  operation     ....  268 

239.  Same  as  Fig.  237.     Flap  is  turned  into  place  and  the  implanted 

bone  ends  are  fastened  to  the  freshened  end  of  the  jaw  fragments  269 

240.  Lateral  implantation  of  osteoplastic  flap  from  clavicle 27  0 

241.  Lateral  implantation  of  osteoplastic  flap  from  the  neck  and  clavicle  271 

242.  Method   of  grasping  the  jaw  through  the  intact  skin  to  draw  it 

forward 272 

243.  Author's  method  of  repairing  defect  due  to  scar  tissue     ....  275 

244.  Esser's  method  of  repairing  defect  due  to  scar  tissue 275 

245.  Restoration  of  the  upper  lip 276 

246.  An  acquired  defect  of  the  palate 277 

247.  Repair  of  an  acquired  palate  defect 277 

248.  X-ray  of  undeveloped  lower  jaw 279 

249.  Occlusion  of  the  teeth,  viewed  from  behind 280 

250.  Jaw  deformity  resulting  from  premature  loss  of  the  first  molar 

tooth 281 

251.  Greek  profile 282 

252  Negro  profile 282 

253.  Cast  showing  protrusion  of  the  lower  jaw 283 

254.  Skull  showing  retraction  of  the  lower  jaw 283 

255.  Diagram  after  Hunter,  illustrating  growth  of  the  lower  jaw     .     .  284 

256.  Casts  of  a  case  of  an  open  bite 285 

257.  Photograph  of  a  case  of  an  open  bite 285 

258.  Correction  of  retraction  of  the  mandible  by  orthodontic  appliance, 

Lischer 289 

259.  Correction  of  retraction  of  the  mandible  by  orthodontic  appliance, 

Lischer 290 

260.  Transverse  section  of  the  face,  diagrammatic 291 

261.  Subcut&neous  section  of  the  ramus  of  the  mandible 292 

262.  Needle  for  passing  a  wire  saw  around  the  ramus 292 

263.  Dilator  for  forceful  opening  of  the  mouth 292 

264.  X-ray  showing  the  ramus  cut  and  the  body  of  the  jaw  moved  for- 

ward     293 

265.  Lateral  deviation  of  the  chin 293 

266.  Lateral  deviation  of  the  chin,  corrected 293 

267.  Jaw  wired  in  position  after  section  of  the  ramus 295 

268.  Obliquity  of  the  chin 296 


ILLUSTRATIONS.  xxvil 

FIGURE  ,  PAGE 

269.  Retracted  mandible  brought  forward  by  operation 296 

270.  Retraction  of  the  mandible,  full  face 297 

271.  Operative  correction  of  retraction  of  the  mandible,  full  face     .     .     .  298 

272.  Retraction  of  the  mandible,  profile 299 

273.  Operative  correction  of  retraction  of  the  mandible,  profile     .     .     .  300 

274.  Cast  showing  protrusion  of  the  lower  jaw 301 

275.  Cast  showing  protrusion  of  the  lower  jaw 301 

276.  Cast  showing  protrusion  of  the  lower  jaw,  corrected  by  operation  301 

277.  Protrusion  of  the  lower  jaw,  correction  by  orthodontic  appliance, 

Lischer 302 

278.  Protrusion  of  the  lower  jaw,  correction  by  orthodontic  appliance, 

Lischer 303 

279.  Bone  cuts  for  resection   of  the   lower  jaw  for  the   correction   of 

protrusion 304 

280.  Reconstruction  of  the  lower  jaw  after  resection 304 

281.  Double-bladed  saw 305 

282.  Submucous  resection  of  the  lower  jaw 307 

283.  Modified  Angle  splint  for  resected  lower  jaw 308 

284.  Modified  Angle  splint,  adjusted  after  resection  of  the  jaw     .     .    ,.  308 

285.  Fixation  of  the  jaw  by  wires,  after  resection 309 

286.  Correction  of  open  bite  by  simple  section  of  the  body  of  the  jaw     .  309 

287.  Open  bite  corrected  by  V-shaped  excision  of  the  body  of  the  jaw     .  311 

288.  Open  bite  corrected  by  an  S-shaped  section  in  the  body  of  the  jaw  311 

289.  Wooden  dilator  for  stretching  scar  bands 316 

290.  Apparatus  for  gradual  separation  of  jaws  in  trismus     .     .     ...     .  316 

291.  Ankylosis  with  retraction  of  the  chin 317 

292.  Pneumatic  dilator  for  fibrous  ankylosis 318 

393.  Showing  inability  to  open  mouth  after  extensive  removal  of  car- 
cinoma, and  correction  of  defect 319 

294.  X-ray  showing  normal  mandibular  joints 320 

295.  X-ray  showing  ankylosis  of  the  temporomandibular  joints     .     .     .  321 

296.  Skin  incision  for  resection  of  the  joint 323 

297.  X-ray  showing  resection  of  the  joint 323 

298.  Natural  limit  of  opening  in  a  case  of  ankylosis 321 

299.  Limit  of  opening  immediately  after  reconstruction  of  the  joint     .     .  324 

300.  Mouth  blocked  open  after  reconstruction  of  the  joint 324 

301.  Final  opening  obtained  after  reconstruction  of  the  joint     ....  324 

302.  Opening  temporarily  obtained  after  section  of  the  ramus     ....  324 

303.  Ankylosis  with  retraction  of  the  chin 325 

304.  Operative  result  in  a  case  of  ankylosis 326 

305.  Reconstruction  of  the  temporomandibular  joint 327 

306.  Nasal  bridge  supported  from  the  teeth 329 

307.  Showing   deformity    of   nose    from    blow    received,    and    result    of 

correction 330 

308a. Diagrammatic   representation   of  the  right  costal   cartilage   from 

which  cartilaginous  grafts  are  obtained 331 

308b. Depressed  bridge  elevated  by  cartilage  transplant 331 

309.  Deformity  of  the  nose  from  injury,  showing  result  of  correction     .  332 

310.  Too  prominent  bridge,  showing  the  result  of  correction     ....  333 
311-313.  Technique  of  constructing  nose    when   totally    absent     .     .     .  336 


xxviil  ILLUSTRATIONS. 

FIGURE  PAGE 

314.  Upper  incisor  and  bicuspid  forceps 341 

315.  Right  and  left  upper  molar  forceps 341 

316.  Bayonet  root  forceps 341 

317.  Hawk-bill  forceps  for  lower  anterior  teeth 841 

318.  Hawk-bill  lower  molar  forceps 341 

319.  Universal  forceps •     •     •  341 

320.  Slender  root  forceps 341 

321.  Root  elevators 341 

322.  Root  elevator 342 

323.  Elevator  for  removing  impacted  lower  third  molars 342 

324.  Impacted  upper  third  molar 346 

325.  Noma 356 

326.  Route  for  infection  at  apex  of  root  via  pulp  canal 374 

327.  Route  for  infection  and  detachment  of  peridental  membrane  along 

side  of  root 374 

328.  Acute  abscess  penetrating  periosteum 375 

329.  Acute  abscess  lifting  periosteum 375 

330.  331.  Plaster  models  of  case  of  chronic  abscess  with  a  sinus     .     .     .  377 

332.  Radiograph  showing  a  chronic  alveolar  abscess  at  the  root  of  upper 

lateral  incisor 378 

333.  Radiograph  showing  two  blind  alveolar  abscesses 378 

334.  Showing  destruction  of  lower  jaw-bone  by  chronic  alveolar  abscess  379 

335.  Gum  and  bone  destruction   due  to  tartar  deposit  without   pocket 

formation 380 

336.  Deposit  of  serumal  calculus  under  the  free  gingiva 380 

337.  Bone  absorption  resulting  from   pyorrhea  alveolaris 381 

338.  Radiogi'aph  showing  extensive  destruction  of  the  bone  and  alveolar 

process  in  a  case  of  chronic  suppurative  pericementitis    ....  382 

339.  Explorers  for  measuring  the  depth  of  pus  pockets 383 

340.  Infection   around  unerupted  teeth 384 

341.  X-ray  of  chronic  bone  abscess 385 

342.  Inflammatory  destruction  of  bone 387 

343.  Necrosis  of  the  jaw-bone 387 

344.  Acquired  perforation  of  the  palate 389 

345.  Leontiasis  ossea 390 

346.  Rubber  drain 393 

347.  Steel  probe 395 

348.  Unerupted  third  molar 396 

349.  Diagram  of  bone  abscess 400 

350.  Diagram  of  the  treatment  of  bone  abscess 400 

351.  Result   of   gum   amputation   for   the   cure    of   a   pocket    on   buccal 

surface  of  the  anterior  root  of  first  lower  molar 405 

352.  Amputation  of  the  distal  root  of  a  lower  first  molar 405 

353.  Operation  for  elimination  of  pus   pockets 406 

354.  Submaxillary  incision  for  induration  of  the  floor  of  the  mouth     .     .  413 

355.  Submaxillary  incision  completed 414 

356.  Submaxillary  incision  completed 415 

357.  Result'    of    operation 416 

358.  Drilling  the  antrum 421 

359.  Self-retaining  temporary  drain  in  antrum 421 


ILLUSTRATIONS.  xxix 

FIGURE  PAGE 

360.  Denker  operation 424 

361.  Denker   operation 425 

362.  Calcified  antral  cyst 426 

363.  Hypertrophy  of  the  gums 427 

364.  Epulis 428 

365.  Osteoma 430 

366.  Ossicles  from   jaw  tumor 431 

367.  Follicular  odontoma 432 

368.  Cementoma 432 

369.  Cementoma      . 432 

370.  Composite  odontoma 432 

371.  Inflammatory  cyst  of  the  jaw 433 

372.  Bone  cyst 433 

373.  Supernumerary  teeth 434 

374.  Cystic  adamantinoma 440 

375.  Cystic  adamantinoma 440 

376.  Excision  of  the  upper  alveolar  process 455 

377.  Kocher  incision  for  excision  of  the  maxilla 458 

378.  Total  excision  of  the  maxilla     . 458 

379.  Ostoplastic  resection  of  the  maxilla 458 

380.  Excision  of  the  lower  alveolar  process 462 

381.  Occlusion,  after  excision  of  one  half  of  the  mandible 464 

382.  Scar  band  limiting  the  opening  of  the  mouth 464 

383.  Result  obtained  by  releasing  the  scar  band 464 

384.  Marten   splint 464 

385.  Buried  silver  splint 465 

386.  Scar  resulting  from  noma 469 

387.  Lymphangioma   of   the   face 473 

388.  Lymphangioma  of  the  face,  result  of  the  treatment 473 

389.  Inoperable  cancer  of  the  mouth 477 

390.  Submental  incision  for  cancer  of  the  lip 479 

391.  Lymphatic  excision  in  the  upper  part  of  the  neck 480 

392.  Diagram  of  location  of  sublingual  dermoids 488 

393.  Operation  for  sublingual  cyst 489 

394.  Exposure  of  the  parotid  gland 495 

395.  Bilateral  parotid  abscess  following  operation  for  suppurative  ap- 

pendicitis      495 

396.  Packing  in  place  after  exposure  of  parotid  gland 496 

397.  Showing  extent  of  wound  after  removal  of  first  packing     ....  496 

398.  Symmetrical  action  of  the  facial  muscles 496 

399.  Inconspicuous  scar  one  year  after  exposure  of  parotid  gland     .     .  496 

400.  Congenital  fistula  of  the  parotid  duct  restored  by  construction  of 

a  new  duct  from  the  skin  and  mucous  lining  of  the  cheek     .     .     .  498 

401.  Relations  of  the  parotid  duct 512 

402.  Excision  of  the  parotid  gland,  first  step 519 

403.  Excision  of  the  parotid  gland,  second  step 520 

404.  Excision  of  the  parotid  gland,  completed 521 

405.  Scar  from   suppurating   thyroglossal    fistula 546 

406.  Thyroglossal  fistula 547 

407.  Operation  for  invading  the  retrohyoid  region 548 


XXX  ILLUSTRATIONS. 

FIGURE  PAGE 

408.  Lymphatics  of  the  tongue 561 

409.  V-shaped  excision  from   the   tongue 582 

410.  Excision  of  one  half  of  the  tongue  from  within  the  mouth,  third  step  583 

411.  Excision  of  one  half  of  the  tongue  from  within  the  mouth,  fourth 

step 584 

412.  Diagrammatic  coronal  section  of  the  tongue 585 

413.  Excision  of  one  half  of  the  tongue  within  the  mouth,  completed     .  586 

414.  Excision  of  the  deep  cervical  lymphatics 599 

415.  Paralysis  of  the  lower  lip  following  the  submaxillary  operation  .  602 

416.  Branchial  fistula   of  first  cleft 608 

417.  Branchial  fistula  of  the  second  cleft 608 

418.  Incision  into  the  anterior  faucial   pillar 617 

419.  Anastomosis  of  the  facial  nerves 640 

420.  Injection  of  the  facial  nerve 642 

421.  Anomalous  distribution  of  the  first  division  of  the  fifth  nerve     .     .  646 

422.  Anomalous  distribution  of  the  first  division  of  the  fifth  nerve     .     .  646 
428.  Pain  spots  in  tic  douloureux 646 

424.  Pain  spots  in  tic  douloureux 646 

425.  Pain  spots  in  tic  douloureux 647 

426.  Radiation  of  pain  in  tic  douloureux 647 

427.  Needle  for  deep  injections 653 

428.  Injection  of  the  mandibular  nerve 655 

429.  Position  of  the  patient  during  injection 656 

430.  Course    of   the   needle    during    injection    of   the    second    and   third 

division 657 

431.  Osteoporosis   of  the  skull 658 

432.  Osteoporosis  of  the   orbit 661 

433.  Injection  of  the  first  division  of  the  fifth  nerve 662 

434.  Anesthesia  after  injecting  the  second  division  of  the  fifth  nerve     .  663 

435.  Anesthesia  after  injecting  the  second  division  of  the  fifth  nerve     .  663 

436.  Anesthesia  after  injecting  the  first  and  second  divisions  of  the  fifth 

nerve 664 

437.  Anesthesia  after  injecting  the  first  and  second  divisions  of  the  fifth 

nerve 664 

438.  Anesthesia  after  injecting  the   second  and  third  divisions   of  the 

fifth  nerve 665 

439.  Incision    for    approaching    the    posterior    root    of    the     Gasserian 

ganglion 665 

440.  Rubber  head  apron  on  standard 667 

441.  Rubber  head  apron  in  position 668 

442.  Incision    for    approaching    the    posterior    root    of    the     Gasserian 

ganglion 669 

443.  Avulsion    of   the   posterior  root  of    the    Gasserian    ganglion — Ex- 

posure of  the  dura 670 

444.  Avulsion   of   the  posterior  root  of  the   Gasserian   ganglion — Path 

traversed  along  the  floor  of  the  middle  cerebral  fossa     ....  671 

445.  Avulsion  of  the  posterior  root  of  the  Gasserian  ganglion — Display 

of  the  middle  meningeal  artery 672 

446.  Avulsion  of  the  posterior  root  of  the  Gasserian  ganglion — Ligation 

of  the  middle  meningeal  artery 673 


ILLUSTRATIONS.  XXXI 

FIGURE  •  PAGE 

447.  Avulsion  of  the  posterior  root  of  the  Gasserian  ganglion — Display 

of  the  root  and  the  ganglion 674 

448.  Porcelain   dissolving  cups 679 

449.  Glass   measure  for  local   anesthetics 680 

450.  Hermetically  sealed  glass  ampuls 681 

451.  Thoma  sterilizer 682 

452.  Novocain  armamentarium 683 

453.  Subperiosteal   injection    of   a    canine   tooth — Prinz 685 

454.  Subperiosteal  injection  of  a  molar  tooth — Prinz 685 

455.  Subperiosteal,   peridental,   and   intraosseous   injection   of  a   canine 

tooth — Prinz 685 

456.  Peridental  injection  of  a  premolar  tooth — Prinz 685 

457.  Perineurial  injection  of  the  upper  teeth — Prinz 687 

458.  Rupert  apparatus  for  administration  of  ether  vapor  spray     .     .     .  692 

459.  Richardson  apparatus  for  intratracheal  anesthesia 693 

460.  Armamentarium  for  infiltration  anesthesia 694 


CHAPTER  I. 

PHYSICAL   EXAMINATION— ANATOMICAL 
CONSIDERATIONS. 

During  the  physical  examination,  at  least  mental  note  must  be  made 
of  the  condition  of  all  the  essential  and  correlated  structures  of  the 
mouth. 

EXAMINATION. 

The  adult  to  be  examined  should,  if  possible,  be  placed  in  a  sitting 
posture.  The  light,  which  may  be  direct  or  reflected  from  a  head 
mirror,  should  be  good.  To  inspect  the  posterior  part  of  the  tongue 
or  the  nasopharynx,  a  head  mirror  and  laryngoscopic  or  rhinoscopic 
mirror  are  necessary.  One  of  the  latter  may  also  be  used  in  place  of  a 
dental  mirror.  A  comfortably  fitting,  broad  tongue  depressor  is  pref- 
erable to  the  handle  of  a  spoon.  Cocain^  may  be  necessary  to  satis- 
factorily conduct  certain  details.  If  there  is  an  overhanging  mustache, 
it  should  be  brushed  or  held  well  out  of  the  way.  The.  hands  of  the 
surgeon  should  be  well  washed,  either  in  the  presence  of  the  patient  or 
in  an  adjoining  room,  and  the  odor  of  tobacco,  especially  in  examining 
women,  should  be  entirely  eliminated. 

It  is  sometimes  almost  impossible  to  make  a  satisfactory  examina- 
tion of  a  struggling  child,  but  patience  and  kindness  will  be  successful 
in  nearly  every  case.  As  a  rule,  children  resist  because  they  are  fright- 
ened, and  it  is  better  to  spend  a  little  time  in  making  friends  than  to 
risk  prolonging  strained  relations  by  a  forced  examination.  If  the 
examination  or  treatment  must  be  done  forcibly^  it  is  best  accomplished 
by  seating  the  child  upon  the  nurse's  lap,  with  its  body  well  against  her. 
With  one  hand  pressed  on  the,  forehead,,  she  holds  the  child's  head 
against  her  shoulder  or  forehead;  withtlje  other  arm  she  controls  its 
arms  and  body. 

Infants  are  best  examined  lying  on  the  back  on  the  nurse's  lap,  with 
the  feet  toward  her  body  and  the  head  hanging  between  her  knees,  with 
the  face  toward  the  surgeon  and  the  light.  The  arms  may  be  swathed 
to  the  body  by  a  large  towel  or  sheet,  but  if  this  is  done,  it  should  be 
done  effectually. 

A  history  should  be  obtained,  not  only  of  the  affection  for  which 
relief  is  sought,  but  also  the  hereditary  and  personal  history  of  any  and 


'^The  word   cocain   Is   used  here  as  the   generic   term   for  local   anesthetics   of 
this  class. 


2  SURGERY  OF  THE  MOUTH  AND  JAWS. 

all  conditions  that  may  bear  upon  it.  It  should  always  be  borne  in 
mind  that  the  mouth  is  an  integral  part  of  the  body,  that  it  may  show 
local  expressions  of  general  diseases,  and  that  local  diseases  are  apt  to 
have  more  or  less  effect  on  the  whole  organism. 

If  a  rash  is  present,  its  character  and  distribution  should  be  studied, 
and  its  possible  relationship  to  a  local  irritation  or  a  general  disease 
considered.     A  sinus  should  be  recognized  and  its  cause  determined. 

In  examining  an  ulcer,  the  surgeon  should  determine  the  character 
of  its  base,  its  edge  and  its  discharge,  the  presence  or  absence  of  pain, 
the  condition  of  the  surrounding  tissue,  local  and  distant ;  their  number 
and  position  should  be  noted,  and  their  cause  sought.  An  ulcer  is  a 
process  of  disintegration  which  is  more  intelligible  to  us  than  are 
formative  changes.  Sometimes  the  cause  of  the  ulceration  is  as  evi- 
dent as  the  ulcer  itself.  With  ulcers  of  uncertain  character,  a  diag- 
nosis is  often  facilitated  by  a  microscopic  examination  of  the  discharge 
or  scrapings  made  from  the  ulcer,  or  preferably  from  a  piece  removed 
from  the  edge  and  base. 

The  character  of  a  tumor  or  a  swelling  can  usually  be  more  or  less 
accurately  diagnosed  by  following  the  scheme  planned  by  Pierce  Gould, 
which  includes  attention  to  the  following  points :  its  position,  the  de- 
termination of  the  structure  in  which  located,  its  manner  of  onset,  its 
physical  characteristics,  its  life  history,  its  mode  of  growth,  presence 
or  absence  of  pain,  its  evidence  of  infectivity — local  and  distant,  the 
effect  of  the  growth  on  the  general  condition  of  the  patient,  and  when 
necessary,  a  laboratory  examination  of  its  tissues  or  its  aspirated 
contents. 

Microscopic  and  macroscopic  examination  should  be  made  of  patho- 
logic discharges,  while  bacteriologic  cultures  will  often  shed  further 
light. 

Pain  may  result  from  local  or  distant  causes.  A  carious  tooth  may 
cause  pain  at  its  site,  or  a  neuralgia  in  the  ear  or  in  some  distant  point. 
Tenderness  on  pressure  is  always  due  to  a  local  lesion.  Referred  pain, 
induced  by  pressure,  may  be  due  to  impulses  transmitted  through 
nerves.  Touching  the  cheek  may  start  a  paroxysm  of  tic  douloureux 
at  some  other  point.  The  pressure  itself  may  be  transmitted  to  a  dis- 
tant site.  Pressing  on  the  angles  of  the  jaw  will  cause  pain  at  the  site 
of  a  fractured  symphysis. 

MOUTH  CAVITY. 

The  mouth  is  a  part  of  the  face.  The  latter  consists  of  a  series  of 
bony  partitions,  covered  with  soft  structures,  attached  to  the  fore  part 
of  the  under  surface  of  the  brain  case.  These  partitions  inclose  spaces 
that  contain  either  air  or  special  organs.     The  mouth  is  most  inferiorly 


ANATOMICAL  CONSIDERATIONS.  3 

situated  of  these  facial  spaces,  is  the  beginning  of  the  ahmentary  canal, 
and  an  accessory  air  passage.  With  its  contents,  it  is  the  organ  of 
mastication,  taste,  and  articulate  speech  (Fig.  1). 

The  teeth  and  gums  separate  the  mouth  cavity  proper  from  an  outer 
space,  which  is  called  the  vestibule. 

The  palate,  which  is  bony  in  its  anterior  five  eighths,  forms  the  roof 
of  the  mouth,  from  which  it  separates  the  nasal  fossae  and  the  nasal 


Obliquus  superior  muscle 

Levator  palpebrse  superioris  muse 

Rectus  superior  muscle     ... 


Eyeball 
Superior  lacrymal  gland. 


Rectus  Internus  muscle 
Rectus  externus  muscle 
Rectus  inferior  muscle, 
Obliquus  inferior  muscle 


Buccal  fat 

Masseter  muscle... . 

Palatina  major  artery.  . 

Palatine  gland     . 

Buccinator  muscle 

Gingiva 

Platysma  muscle 
Geniohyoglossus  mu&tle 

Mandible..  . 
Geniohyoid  muscle 
Mylohyoid  muscle 
Digastric  muscle 


Frontal  sinus. 

Probe  in  the  infundibulum. 


Middle  turbinated  bone. 

Uncinate  process. 

Middle  nasal  meatus. 

Mouth  of  the  maxil- 
lary antrum. 
Nasal  septum. 

.Inferior  nasal  meatus. 

Inferior  turbinated  bona 

Maxillary  antrum. 

...Palatine  process  of  the 
maxilla. 

Alveolar  process. 
Cavity  of  the  mouth. 
Vestibule  of  the  mouth. 
Tongue. 
Ranine  artery. 


Plica  sublingualis. 

.Submaxillary  duct. 
.  ..Lingual  nerve. 
Sublingual  gland. 

"_ Platysma  muscle. 


Fig.   1.     Coronal  section  through  the  face. — From  Spalteholz. 


pharynx,  and  in  some  instances,  from  one  or  both  of  the  maxillary 
sinuses. 

Anteriorly  and  laterally  the  cavity  is  bounded  by  the  alveolar  pro- 
cesses and  teeth  of  the  upper  jaw,  and  by  the  teeth,  alveolar  processes, 
and  body  of  the  lower  jaw.  Posteriorly  it  communicates,  by  the  wide 
space  between  the  fauces,  with  the  shallow  oral  pharynx,  which  pos- 
teriorly rests  on  the  bodies  of  the  cervical  vertebrae. 


4  SURGERY  OF  THE  MOUTH  AND  JAWS. 

FLOOR  OF  THE  MOUTH. 

The  floor  of  the  mouth  consists  really  of  a  muscular  plane,  which 
separates  the  mouth  and  its  contained  structures  from  the  neck  below. 
For  convenience,  however,  the  structures  lying  along  its  upper  surface 
are  spoken  of  as  being  in  the  floor  of  the  mouth,  and  all  of  these,  with 
their  intraoral  mucous  covering,  are  referred  to  as  the  floor  of  the 
mouth. 

The  muscular  floor  is  formed  by  geniohyoid  muscles  and  the  un- 
paired mylohyoid  muscle,  which  stretches  between  two  concentric  bony 
arches  from  the  concavity  of  the  body  of  the  mandible  to  the  convexity 
of  the  body  of  the  hyoid  bone.  Behind  this,  within  the  concavity  of  the 
hyoid  bone,  the  air  and  food  passages  proceed  downward  from  the  oral 


.Coronoid  process 


Ramus  of  tbe  lower  jaw 

(  small  cornu 

Hyoid  bone   -,  , 

I  large  cornu. 


Mylohyoid  muscle. 
Geniohyoid  muscle. 


Fig.   2.      Muscles  that  form  the  floor  of  the  mouth  stretching  between  the  concavity 
of  the  body  of  the  mandible  and  the  convexity  of  the  hyoid  bone. — From  Spalteholz. 


pharynx  into  the  neck.  The  lateral  walls  and  most  of  the  roof  of  the 
mouth  are  of  unyielding  tissue,  and  when  closed,  it  is  through  the 
muscular  floor  that  adjustment  of  capacity  is  accomplished  (Fig.  3). 
Except  through  a  central  vertical  septum  composed  of  the  genio- 
hyoglossi  muscles,  nowhere  is  the  tongue  in  contact  with  the  muscular 
floor.  This  is  best  illustrated  by  referring  to  coronal  and  sagittal  sec- 
tions of  the  mouth  (Fig.  1).  The  space  between  the  body  of  the 
tongue  and  the  muscular  floor  is  divided  into  two  lateral  compartments 
by  this  muscular  septum.  Each  of  these  subspaces  is  bounded  below 
by  the  muscular  floor,  externally  by  the  body  of  the  mandible,  medially 
by  the  geniohyoglossi  and  geniohyoid  muscles,  and  above  by  the  reflec- 
tion of  the  mucous  membrane  upon  which  the  body  of  the  tongue  rests. 
In  these  compartments  are  the  structures  that  are  spoken  of  as  being  in 
the  floor.     Anteriorly  these  spaces  are  limited  by  the  mental  portion  of 


ANATOMICAL  CONSIDERATIONS.  5 

the  mandible,  while  posteriorly,  between  the  root  of  the  tongue  and  the 
angle  of  the  jaw,  they  open  freely  into  the  intermuscular  connective 
tissue  spaces  of  the  neck.  It  is  these  posterior  intermuscular  spaces  that 
afford  entrance  and  exit  to  the  vessels,  nerves,  and  ducts  that  are  found 
in  the  floor.  Within  the  floor  of  the  mouth  are  contained  the  lingual 
vein,  lingual  nerve,  and  submaxillary  duct.  The  lingual  artery  lies  buried 
in  the  under  surface  of  the  tongue.  Within  the  floor  of  the  mouth  and 
in  the  under  surface  of  the  tongue  are  several  excretory  glands,  mucous 
and  salivary. 


Labial  commis- 
sure  


Fig.  3.     Mucous  reflections  under  the  anterior  of  the  tongue. — Prom  Spalteholz. 

Glands  of  Nuhn  and  Blandin. — Blandin  first  described  a  gland 
lying  on  the  under  surface  of  the  tongue,  near  the  tip,  on  either  side 
of  the  midline,  about  the  size  of  an  ordinary  almond.  Each  gland  has 
one  or  two  excretory  ducts  opening  on  the  under  surface  of  the  tongue. 
Cysts,  stones,  and  tumors  occur  in  connection  with  these  glands. 

Incisive  Glands. — Besides  the  glands  of  Nuhn  and  Blandin, 
Suzanne  and  Merkel  have  described  a  group  of  glands  on  either  side, 
lying  in  front  of  the  salivary  caruncle  and  just  behind  the  periosteum 
of  the  jaw. 

Tillau  and  Fleischniann  describe  an  inconstant  sublingual  bursa  on 
either  side  between  the  geniohyoglossi  muscles  and  the  mucous  mem- 
brane lying  between  the  frenum  and  the  sublingual  gland.     This  has 


6  SURGERY  OF  THE  MOUTH  AND  JAWS. 

been  credited  as  the  cause  of  acute  ranula.  Merkel  and  others  have 
denied  the  existence  of  this  bursa. 

Bochdalek's  Glands. — Bochdalek's  glands  are  certain  remnants 
containing  ciliated  epithelium  supposed  to  be  derived  from  the  thyro- 
glossal  tract,  which  is  often  called  the  thyroglossal  duct.  Chronic  ob- 
struction of  the  excretory  duct  of  an  incisive,  a  Bochdalek,  or  a  sub- 
lingual salivary  gland  causes  a  cyst  known  as  ranula. 

The  sublingual  salivary  glands  consist  of  lobules  lying  on  the  floor 
of  the  mouth  beneath  the  submaxillary  duct.  The  submaxillary  sali- 
vary gland  lies  mostly  outside  of  the  mouth,  beneath  the  mylohyoid 
muscle.  Part  of  the  gland,  however,  containing  the  common  excre- 
tory duct,  bends  around  the  posterior  border  of  this  muscle,  and  comes 


Apex  of  the  tongue 


Gland  of  Nuhn  and  Blandin 


Styloglossus  muscle 


Geniohyoglossus 
muscle 


Sublingualis  muscle 


Gland  of  Nuhn  and  Blandin. 

-J^-i- Lingual  vein. 

4^  _y_ Lingual  nerve. 

Ranine  artery. 


Sublingual  gland  — 

Submaxillary  duct 
Great  sublingual  duct- 

Sublingual  caruncle 

Fig.  4.     Structures  lying  beneath  and  within  the  anterior  part  of  the  tongue. — After 
Spalteholz. 


to  lie  above  the  muscle  within  the  floor.     The  duct  is  continued  along 
the  upper  surface  of  the  mylohyoid  muscle  and  sublingual  gland. 

On  either  side  of  the  junction  of  the  frenum  of  the  tongue  with  the 
floor  is  a  small  papilla,  on  which  may  be  seen  the  openings  of  the  sub- 
maxillary ducts.  Running  backward  from  this,  at  the  bottom  of  the 
sulcus,  are  two  elevated  ridges  of  mucous  membrane,  under  which  lie 
the  sublingual  glands,  and  through  the  crest  of  which  the  sublingual 
ducts  open  (Figs.  3  and  4).  These  ridges,  the  plicje  sublingualis,  also 
mark  the  course  of  the  ducts  of  the  submaxillary  glands,  the  lingual 
nerve,  and  the  lingual  vein,  which  lie  along  the  floor  of  the  mouth  to 
the  median  side  of  the  sublingual  gland.  The  lingual  nerve  enters  the 
floor  of  the  mouth  from  above,  just  to  the  inner  side  of  the  body  of  the 
mandible,  and  can  be  felt  by  pressing  the  tip  of  the  finger  against  the 
bone  below  the  last  molar  tooth. 


ANATOMICAL  CONSIDERATIONS.  7 

With  one  finger  in  the  sulcus  and  two  fingers  of  the  other  hand 
thrust  under  the  jaw  from  without,  the  sublingual  gland  in  front,  and  the 
submaxillary  gland,  posteriorly,  can  be  distinctly  outlined,  unless  there 
is  too  much  fat.  In  the  normal  condition  the  submaxillary  duct  cannot 
be  felt,  but  a  stone  in  the  duct,  or  the  thickening  around  it,  can  always 
be  detected.  In  carrying  on  this  examination  of  the  floor,  the  mouth 
should  be  moderately  open,  with  the  head  bent  slightly  forward,  to  re- 
lax the  muscles  of  the  floor  and  the  platysma.  The  fingers  of  one  hand 
should  steady  the  structures  while  they  are  being  palpated  by  the  other. 
In  examining  for  stone  in  the  duct,  it  is  possible  to  pass  a  probe  into 
the  duct  from  the  opening  in  the  papilla.  The  connective  tissue  in  the 
floor  of  the  mouth  is  very  lax.  In  certain  inflammatory  conditions  it 
may  become  rapidly  infiltrated  with  serum  until  the  mucous  membrane 
is  raised  up  in  a  roll  above  the  level  of  the  gums,  and  the  tongue  is 
pushed  before  it. 

TONGUE. 

The  tongue  in  the  normal  state  of  rest  is  entirely  within  the  mouth. 
The  body  occupies  the  upper  portion  of  the  cavity,  and  the  dorsal  sur- 
face presents  an  antero-posterior  convexity  that  approximates  a  half 
circle.  When  the  mouth  is  opened,  the  body  follows  the  movements 
of  the  lower  jaw  (Fig.  5).  It  is  anchored,  by  relatively  small  mus- 
cular attachments,  posteriorly  to  the  body  of  the  hyoid  bone  and  an- 
teriorly to  the  symphysis  of  the  mandible.  Its  mucous  reflections  and 
some  extrinsic  muscles  further  limit  its  excursion  and  determine  its 
shape.  Nowhere  is  it  attached  or  supported  by  ligaments.  The  mobil- 
ity of  the  tongue  is  further  augmented  by  the  fact  that  the  hyoid  bone 
is,  in  turn,  dependent  for  its  position  entirely  on  the  muscles  to  which 
it  furnishes  attachment. 

Far  back  on  the  tongue,  and  best  seen  with  a  mouth  mirror,  is  the 
sulcus  terminalis,  a  scarcely  visible  V-shaped  furrow  on  the  dorsal  sur- 
face. It  runs  from  the  attachment  of  the  anterior  faucial  pillar,  on 
either  side,  backward  and  toward  the  median  line  to  the  foramen 
cecum,  which  latter  marks  the  upper  termination  of  the  thyroglossal 
duct  or  tract.  Slightly  in  front  of  and  parallel  with  the  sulcus  termi- 
nalis is  a  V-shaped  row  of  large  taste  papillae,  known  as  the  circum- 
vallate.  These,  by  their  supply  through  the  glossopharyngeal  nerve, 
are  related  to  the  pharyngeal  portion  of  the  organ. 

That  portion  of  the  tongue  behind  the  sulcus  is  called  the  root,  and 
is-  morphologically  related  to  the  pharynx ;  while  that  in  front  is  the 
body,  and  is  derived  from  the  primitive  buccal  cavity.  The  root  of  the 
tongue  forms  most  of  the  anterior  wall  of  the  oral  pharynx. 

The  mucous  covering  of  the  pharyngeal  surface  continues  on  to  the 


8  SURGERY  OF  THE  MOUTH  AND  JAWS. 

fauces  and  the  lateral  pharyngeal  walls.  Below  it  is  reflected  on  to 
the  front  of  the  epiglottis  and  forms  the  middle  glossoepiglottic  fold. 
This  part  of  the  mucous  membrane  is  much  more  sensitive  to  pain  than 
that  over  the  dorsum,  and  in  examination,  unless  cocainized,  should 
not  be  touched  by  the  tongue  depressor.     The  submucous  tissue  of  this 


Upper  lip 

Tongue...., 
Lower  lip... 
Septum  linguEe... _ 


Mandible... 

Genibliyoglossus 

muscle 


Geniohyoid  muscle...' 

Mylohoid  muscle 

Hyoid  bone 


Laryngeal  prominence. 

Thyroid  cartilage.. 

Cricoid  cartilage.. 

Sternohyoid  muscle.. 

Isthmus  of  the  thyroid. 

I     !l< 
sternothyroid  muscle i  -  ll\ 

Spprasternal  space ^ 

Innominate  vein _  I 

Body  of  the  sternum --f^l 


Septum  nasi. 
, Hard  palate. 

-t-     Sphenoidal  sinus. 

•    '  -  Vault  of  the  pharynx. 

■■-     Nasopharynx. 

.    Pharyngeal  opening 

t  ^        of  Eustachian  tube. 

-.^-'■^V    Palatine  gland. 

'    "^^yt    Soft  palate. 

^•-i  -    ...2d  cervical  vertebra. 

...  Foramen  cecum. 

..-  ....Root  of  the  tongue. 

+— ^B  - —^  i^"-^   Thyroglossal  duct. 

Oropharynx. 

'f>~''t~'    Epiglottis. 

^l^ti-    Laryngopharynx. 

.Upper  aperture  of 

'"'^SS  *^®  larynx. 

-.  x-j!         ..Vestibule  of  the  larynx. 

..  Cricoid  cartilage. 
..Laryngeal  cavity. 


.7th  cervical 
vertebra. 

- 1st  thoracic 

vertebra. 

Trachea. 

.  _     ...Esophagus. 

^     ■  -    Innominate 

artery. 


m 


Fig.   5.      Sagittal   section   through  the   midplane  of  the  face. — After  Spalteholz. 


part  contains  mucous  glands  and  heaped-up  lymph  follicles,  the  latter 
constituting  the  lingual  tonsil  (Fig.  6).  This,  with  the  faucial  and 
pharyngeal  tonsils,  makes  a  complete  ring  of  adenoid  tissue  surround- 
ing the  entrance  of  the  pharynx.  There  are  also  mucous  glands  on 
the  dorsal  surface,  and  lateral  borders  in  the  neighborhood  of  the  sulcus 
terminalis  and  circumvallate  papillse,  and  any  of  them  may  give  rise 
to  a  mucous  cvst.     Over  the  dorsum  the  mucous  membrane  is  beset 


ANATOMICAL  CONSIDERATIONS.  9 

with  taste  papiHse.     These  give  the  tongue  a  rough  appearance,  which 
varies  greatly  under  certain  conditions. 

The  mucous  covering  is  reflected  from  the  dorsum  around  the  bor- 
ders to  the  inferior  surface  of  the  body,  which  latter  it  invests  over  the 
greater  part  of  its  extent.  Thence  the  mucus  passes  to  and  across  the 
floor  to  the  gum  and  fauces,  and  while  it  forms  part  of  the  anchorage  of 
the  organ,  this  distribution  permits  of  great  freedom  of  movement  and 
also  of  digital  examination  of  the  body  and  of  the  floor  separately. 


Middle  glossoepiglottlc  fold .1 

Vallecula 

Lateral  glossoepiglot- 
tlc fold , 

Posterior  pillar  of      f^B^W,& 
the  fauces -y-lHHtM 

Tonsil -.Mam^'ryAf 

,>  'fj  *; 
Tonsillar  sinus .iSM?  '•M.'^ fl 

-/^.  -    ^b 

Plica  triangularis ^..+  %.       .l^-'i 

Anterior  pillar  of  the  ^^B    ^''' 

fauces '^^^X<' 

Papillae  lenticulares 

Papillae  conicae....  -  '^_  '/'- 

PapillEB  fungiformes '  ' 

Papillae  filiformes ; 


.Epiglottis 


Root  of  the  tongue.  ^ 
Lingual  tonsil. 
Lingual  follicles. 


*'  ^  -^^ Foramen  cecum. 

...Sulcus  terminalis. 
Papillae  circumvallatae. 

~ Papillae  foliatae. 

Body  of  the  tongue. 

-  ...Upper  surface  of  tongue. 
Raphe  linguae. 

, Lateral  margin  of  the  tongue. 

Tip  of  the  tongue. 


Fig.   6.     Dorsum  of  the  tongue. — After  Spalteholz. 


On  raising  the  tongue,  it  will  be  seen  that  the  mucous  membrane 
on  the  under  surface  is  smooth  in  character,  and  that  it  is  reflected  to 
the  bottom'  of  the  glosso-alveolar  sulcus  in  a  double  fold,  with  a  free 
border  anteriorly  (Fig.  3).  At  the  posterior  limit  of  this  fold  the 
membrane  forms  the  posterior  limit  of  the  glosso-alveolar  sulcus  by 
becoming  continuous  with  the  lower  gum  and  anterior  faucial  pillar 
behind  the  last  molar  tooth.  In  the  anterior  portion  of  this  fold  the 
two  layers  of  mucous  membrane  inclose  but  little  connective  tissue, 
while  posteriorly  they  are  separated  by  the  interposition  of  the  genio- 
hyoglossi  muscles.     Grasping  this  septum  with  the  thumb  and  finger, 


10  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  anterior  border  of  the  muscles  car  be  felt.  The  anterior  non- 
muscular  portion  of  the  septum  is  called  the  frenum.  '  It  may  be  ab- 
normally short  from  above  downward,  and  its  upper  attachment  may 
extend  sufficiently  forward  to  bind  the  tongue  down  in  the  sulcus. 
This  condition  is  known  as  tongue-tie,  and  is  rather  rare.  The  oppo- 
site condition  of  too  great  laxity  of  the  frenum  has  been  reported  to 
have  caused  death  by  suffocation  by  the  tongue  turning  back  into  the 
pharynx. 

Two  elevated  fringes  may  be  seen  on  the  under  surface  of  the 
tongue,  converging  at  its  tip.  These  indicate  the  positions  of  ranine 
arteries.  About  12  millimeters  on  either  side  of  the  frenum  may 
usually  be  seen  the  terminations  of  the  ranine  veins.  These,  with 
other  veins  in  the  sulcus,  may  become  varicose,  in  which  case  a  mass  of 
large  dark  veins  are  seen  under  the  mucous  membrane,  almost  oblit- 
erating the  fore  part  of  the  sulcus.  They  are  soft  and  yielding  to 
touch,  but  fill  as  soon  as  the  pressure  is  removed. 

A  dermoid  cyst  may  be  met  with  on  the  under  surface  of  the  tongue, 
usually  in  the  midline  between  the  two  geniohyglossi  muscles,  and  is 
probably  due  to  an  infolding  of  integument  during  development.  Ac- 
cessory thyroids  may  occur  above  the  mylohyoid  muscle,  and  may  be- 
come, the  seat  of  a  goiter. 

The  surface  in  front  of  the  circumvallate  papillae  is  the  least  movable 
part  of  the  body  of  the  tongue,  and  is  therefore  more  apt  to  be  coated. 
Unilateral  furring  has  been  noted  in  connection  with  irritations  of  the 
fifth  cranial  nerve  of  the  same  side,  but  as  Mr.  Hutchinson  states, 
unilateral  furring  in  the  presence  of  toothache  may  be  due  partly  to 
the  instinctive  immobilization  of  the  tongue  on  that  side.  We  have 
repeatedly  observed  unilateral  furring  in  tic  douloureux. 

The  mucous  membrane  of  the  tongue,  like  that  of  the  mouth,  is 
liable  to  a  variety  of  superficial  lesions.  Aphthse  may  form  upon  the 
tip  and  edges,  thrush  may  occur  in  infants  and  adults  whose  health 
is  broken  down,  herpes  is  occasionally  seen,  and  the  ulcerative  stomatitis 
may  extend  to  it  from  the  cheek  or  palate.  In  addition  to  these,  how- 
ever, and  to  various  kinds  of  specific  diseases — such  as  syphilis  and 
tuberculosis — the  tongue  is  especially  subject  to  certain  forms  of 
chronic  inflammation.  Some  are  superficial,  and  spread  over  the 
greater  portion ;  others  are  local,  and  end  in  deep  ulceration.  On  the 
mucous  surface  of  this  part — or,  in  fact,  over  any  part  of  the  mouth — 
may  develop  one  or  more  white  sodden  i)atclies  of  leucoplakia.  or  a 
])a])i]l()ma  or  nevus  may  be  present. 

The  body  of  the  tongue  is  composed  almost  entirely  of  intrinsic 
muscles.  Between  the  two  halves  of  the  body  is  an  incomplete  fibrous 
septum  corresponding  to  the  median  raphe.     Butlin  is  inclined  to  re- 


ANATOMICAL  CONSIDERATIONS.  '        11 

gard  this  as  analogous  to  certain  fibrous  or  bony  processes  found  in 
connection  with  the  midplane  of  the  tongue  or  body  of  the  hyoid  bone 
in  certain  lower  animals.  Occasionally  fatty  and  cartilaginous  masses 
have  been  found  in  connection  with  the  median  septum  of  the  human 
tongue.  It  is  a  matter  of  clinical  observation  that  cancer  of  one  side 
of  the  body  of  the  tongue  is  very  slow  to  cross  the  median  septum. 

Foreign  bodies  may  become  imbedded  in  the  body  of  the  tongue. 
It  may  be  the  seat  of  gummata  and  many  other  infections.  Dermoid 
cysts,  lipomata,  and  fibromata  occur  in  its  substance,  but  these  benign 
growths  are  rare.  It  is  a  favorite  seat  of  cancer,  which  often  develops 
from  a  papilloma,  leucoplakia,  or  any  chronic  irritation,  but  sarcoma 
of  the  tongue  is  very  rare.  Abscess  of  the  tongue  is  not  common,  but 
it  contains  sufficient  connective  tissue  to  allow  great  swelling;  and  it  is 
sometimes  subject  to  a  congenital  enlargement  known  as  macroglossia. 
Congenital  deformities  of  the  tongue  are  very  rare,  the  commonest  be- 
ing tongue-tie,  or  a  median  cleft  of  the  body.  The  latter  resembles  that 
of  some  lower  animal. 

The  tongue  is  plentifully  supplied  with  blood,  chiefly  from  the 
lingual  arteries,  which  run  near  its  inferior  surface  and  which  have  but 
scanty  intercommunication. 

The  lymphatics  are  especially  large  and  numerous,  and  rapidly 
disseminate  cancer  cells.  They  drain  from  different  areas  into  the 
submental,  submaxillary,  and  superior  and  inferior  deep  cervical  nodes. 
Special  importance  is  attached  to  one  superior  deep  cervical  node  sit- 
uated a  little  above  the  bifurcation  of  the  common  carotid  artery,  which, 
on  account  of  the  numerous  streams  that  reach  it,  has  been  called  the 
principal  node  of  the  tongue. 

The  motor  nerve  supply  of  the  tongue  is  mostly  from  the  hypo- 
glossal. Injury  to  this  nerve  or  its  center,  or  pressure  on  the  nerve  at 
its  foramen  of  exit  or  any  other  point,  will  cause  paralysis  and  atrophy 
on  the  affected  side.  When  protruded,  the  tongue  deviates  toward  the 
paralyzed  side. 

The  tongue  is  well  supplied  with  sensory  nerves  for  both  taste  and 
common  sensation.  Tactile  sensation  is  more  acute  on  the  tip  than  on 
any  other  part  of  the  body.  The  sensory  supply  of  the  pharyngeal  sur- 
face and  the  circumvallate  papillje  is  through  the  glossopharyngeal 
nerve  from  fibers  originally  derived  from  the  trifacial.  This  latter 
nerve  supplies  also  the  oral  part  of  the  organ  directly  through  the 
lingual.  The  taste  papillze  on  the  tip,  sides,  and  dorsum  probably  send 
their  afferent  fibers  through  the  lingual  and  chorda  tympani  nerves. 

Painful  affections  of  the  tongue  in  the  area  supplied  by  the  lingual 
nerve  may  be  accompanied  by  severe  neuralgia  deep  in  the  meatus  of 
the  ear  through  the  connection  of  the  fifth  nerve  with  the  seventh,  or 


12  SURGERY  OF  THE  MOUTH  AND  JAWS. 

it  may  be  over  the  terminal  branches  of  the  fifth.  Spasmodic  contrac- 
tures of  the  muscles  of  mastication  may  result  from  the  same  reflex 
irritation  of  the  fifth.  According  to  Dr.  Head,  irritation  on  the  pharyn- 
geal surface  may  be  associated  with  tender  areas  in  the  skin  of  the 
larynx. 

PALATE. 

The  palate  presents  a  median  raphe,  which  ends  anteriorly  in  the 
incisive  papilla,  which  marks  the  opening  of  the  anterior  palatine  fossa. 
In  infants  this  papilla  is  connected  with  the  frenulum  of  the  lip.  The 
raphe  may  be  raised  by  a  ridge  of  bone  in  the  midline,  the  torus  pala- 
tinus.  Sometimes  a  small  pit  that  will  admit  the  point  of  a  pin  is  seen 
on  each  side  immediately  behind  the  incisive  papilla  about  2  millimeters 
from  the  midline.  These  correspond  to  the  lower  openings  of  Stenson's 
canals. 

In  the  region  of  the  junction  of  the  hard  and  soft  palates  is  usually 
seen  on  each  side  of  the  raphe  a  small  pit,  the  foveola  palatina,  which 
contains  the  excretory  ducts  of  several  palate  glands.  The  palate  ridges 
are  confined  to  the  anterior  part  of  the  hard  palate. 

The  mucous  membrane  and  periosteum  of  the  hard  palate  are  fused 
into  a  single  layer,  which  is  thickest  at  the  edges  and  is  rather  insensi- 
tive. The  vessels  of  the  palate  lie  in  its  deeper  portion,  and  the  de- 
scending palatine  arteries  may  be  felt  pulsating  in  the  posterior  part, 
close  to  the  junction  of  the  palate  with  the  alveolus  (Fig.  7).  In  the 
submucous  tissue  is  a  layer  of  mucous  glands,  which  is  thickest  at  the 
lateral  border  and  at  the  junction  of  the  hard  and  soft  palates.  Large 
mucous  glands  are  found  on  both  surfaces  of  the  uvula. 

The  soft  palate,  or  velum,  is  composed  of  muscle  and  the  palate 
aponeurosis.  It  is  attached  to  the  posterior  border  of  the  hard  palate, 
and  covered  with  mucous  membrane  on  both  surfaces.  From  the  mid- 
dle of  its  posterior  border  hangs  a  fleshy  mass,  the  uvula,  which  helps 
to  close  the  space  between  the  posterior  faucial  pillars  during  the  act 
of  swallowing,  etc.     It  may  be  absent,  bifurcated,  or  abnormally  large. 

The  anterior  faucial  pillars,  arching  from  the  under  surface  of  the 
velum  1  centimeter  in  front  of  its  free  edge,  near  the  base  of  the  uvula, 
pass  downward  and  slightly  forward  to  join  the  tongue  a  little  in  front 
of  the  n-^iddle  of  its  lateral  border.  These  are  made  up  of  the  palato- 
glossi  muscles,  covered  by  mucous  membrane. 

The  posterior  pillars  spring  from  the  posterior  border  of  the  palate, 
and  pass  downward  and  slightly  backward,  to  be  lost  in  the  lateral  wall 
of  the  oral  pharynx.  They  contain  the  palatopharyngei  muscles.  Be- 
tween the  anterior  and  posterior  pillars  lie  the  faucial,  or  oral,  tonsils. 
Just  behind  the  last  upper  molar  tooth  is  the  prominence  of  the  max- 


ANATOMICAL  CONSIDERATIONS. 


13 


illary  tubercle,  and  behind  that  may  be  felt  the  hamular  process  which 
surmounts  the  internal  plate  of  the  pterygoid  process  of  the  sphenoid 
bone.  Over  this  hamular  process  plays  the  tendon  of  the  tensor  palati 
muscle. 

The  upper  surface  of  the  hard  palate  can  be  partially  examined 
through  the  nose  with  a  sound  or  by  inspection.  As  suggested  by 
Kocher,  after  division  of  the  columella  and  the  nasal  septum,  this  ex- 
amination may  be  made  with  the  finger.  The  upper  surface  of  the  soft 
palate  can  be  palpated  from  behind  through  the  oral  pharynx. 


Upper  dental  arch 


Hard  palate. 


Palatine  spine. 
Palatina  major  artery. 


Mouth  of  parotid 
duct. 

Tensor  palati 
muscle. 

Hamular  process. 

Mucous  membrane 

of  the  mouth. 

....Levator  palati 

muscle. 

-f  -.Buccopharyngeus  muscle. 

Palatopharyngeus  muscle. 
..Azygos  uvulae  muscle. 

Palatoglossus  muscle. 
...Upper  surface  of  tongue. 


Gingiva ''       / 

Palatine  glands.. »-- 

Buccinator  muscle -V- 

Pterygomandibular 
ligament 

Tonsil _ 

Fauces '      f^  ' 

Lower  dental  arch... 

Fig.  7.     Submucous  structures  of  the  palate  and  faucial  pillars. — After   Spalteholz. 

The  arch  of  the  palate  varies  in  height,  width,  and  shape.  Marked 
variations  are  usually  credited  to,  or  associated  with,  early  mouth 
breathing.  The  palate  may  show  a  congenital  longitudinal  cleft  in  a 
part  or  the  whole  of  its  length.  It  may  show  the  scars  resulting  from 
the  surgical  repair  of  such  a  deformity,  or  defects  due  to  injuries  or 
distinctive  ulceration. 

The  velum  or  the  fauces  may  be  deformed  by  cicatricial  contrac- 
tion and  adhesions  resulting  from  destructive  inflammations.  The 
palate  is  a  favorite  site  for  gummata  and  resulting  syphilitic  perfora- 
tions, and  in  some  countries  lupus  and  tuberculosis  are  not  uncom- 
mon. Cysts  and  benign  and  malignant  tumors  are  also  found  in 
the  palate,  and  teratomata  may  be  connected  with  it. 


14  SURGERY  OF  THE  MOUTH  AND  JAWS. 

FAUCES  AND  PHARYNX. 

When  the  patient  breathes  deeply  through  the  mouth  with  the  head 
thrown  back,  the  soft  palate  is  raised,  the  pillars  are  separated,  and  the 
uvula,  tonsils,  fauces,  and  walls  of  the  oral  pharynx  are  exposed.  The 
arch  of  the  atlas  corresponds  to  the  hard  palate,  and  the  body  of  the 
axis  to  the  soft  palate  (Fig.  5).  JDie  upper  four,  in  children  the 
upper  six,  vertebral  bodies  can  be  e^^^^K  with  the  finger.  The  pos- 
terior pharyngeal  wall  should  rest  fi^^^f ainst  the  bodies  of  the  ver- 
tebrae, but  may  be  separated  from  them  by  a  postpharyngeal  collection 
of  pus. 

The  examining  finger  can  feel  the  circumvallate  papillse,  lingual 
tonsil,  epiglottis,^^ytenoepiglottic  folds,  and  smaller  laryngeal  car- 
tilages. Passi^^^K  finger  upward  behind  the  velum,  the  vault  of 
the  nasophary^^^^Rterior  part  of  the  nasal  septum  and  Eustachian 
cushions,  and  nWRlarged,  the  pharyngeal  tonsil  may  be  felt.  In  ex- 
amining a  hypertrophied  pharyngeal  tonsil,  the  amount  of  enlargement 
may  be  gauged  by  observing  the  height  to  which  it  rises  on  the  posterior 
border  of  the  septum.  This  may  be  done  with  the  finger  or  with  the 
posterior  nasal  mirror.  Cocain  may  be  necessary  to  make  such  an  ex- 
amination in  the  adult,  but  here  the  laryngoscope  and  posterior  rhino- 
scopic  mirror  will  reveal  what  is  more  readily  felt  in  children. 

The  palate,  fauces,  and  oral  pharynx  in  children  are  especially  liable 
to  injury  from  falling  on  sharp  sticks.  This  may  be  followed  by  a  con- 
dition of  trismus,  not  necessarily  tetanus,  and  requires  an  anesthetic  to 
make  a  satisfactory  examination.  The  lymphatics  from  the  palate  and 
upper  part  of  the  pharynx  pass  to  the  lateral  pharyngeal  and  retro- 
pharyngeal and  to  the  superior  cervical  nodes. 

Besides  the  acute  and  chronic  catarrhs,  the  pharynx  is  subject  to 
secondary  tuberculous  ulcers,  mucous  patches,  snail-tracked  ulcers 
of  secondary  syphilis,  diffuse  gummatous  infiltration,  and  localized 
submucous  gummata.  Benign  tumors  and  both  primary  and  secondary 
malignant  tumors  are  also  found  in  the  pharynx. 

The  oral  tonsils  are  situated  between  the  anterior  and  posterior 
faucial  pillars,  and  rest  on  the  superior  constrictor  muscle  of  the 
pharynx.  When  enlarged,  the  tonsil  may  stand  out  freely  from  the 
pillars,  or  it  may  push  the  anterior  pillar  inward,  in  which  case  it  is 
known  as  a  buried  tonsil.  Often  as  much  or  more  can  be  gained  by 
palpating  the  tonsil  as  by  inspection  (Fig.  7). 

Besides  the  enlargement  of  the  tonsil  itself  from  acute  or  chronic 
inflammation,  there  may  be  infection  and  suppuration  of  the  periton- 
sillar tissue,  with  diffuse  swelling  and  induration  of  the  surrounding 
parts.     If  such   a  collection   of  pus   bursts   through   the  pharyngeal 


ANATOMICAL  CONSIDERATIONS. 


15 


wall,  postpharyngeal  suppuration  will  result.  Chancre,  secondary  snail- 
tracked  ulcers,  and  diffuse  gummata  are  the  syphilitic  lesions  most  com- 
monly found.  Fibroma,  epithelioma,  lymphosarcoma,  and  round-celled 
sarcoma  are  the  tumors  common  to  the  tonsils. 

The  lymphatics  from  the  tonsils  drain  into  the  superior  deep  cervical 
nodes.  An  enlargement  of  one  of  these,  situated  just  behind  the  angle 
of  the  jaw,  is  so  constant  in  tonsillar  infections  that  it  has  been  called 
the  tonsillar  node. 

TEETH. 

The  crowns  of  the  teeth  rise  free  in  the  mouth  above  the  gum  mar- 
gin. The  anterior  teeth  have  incisive  edges,  and  are  for  biting  off  the 
food;  while  the  posterior,  the  molars,  are  broad  and  have  grinding 
surfaces.     The  teeth  between  these,  the  cuspids  and  bicuspids,  are  in- 


Ist,  2d  and  3d  upper  molar 


Maxillary  antrum. 

1st  and  2d  upper  bicuspid. 

Upper  canine. 

....Incisors. 


1st  and  2d  lower 
bicuspid. 


Inferior  dental  canal 

1st,  2d  and  3d  lower  molar 


Mental  foramen. 


Fig.    8.     The    occlusion    of    the    teeth    and    their    position    in    the   jaw-bones. — After 
Spalteholz. 

termediate  in  character  and  function.  Later  in  life,  when  the  teeth  are 
worn  down,  fairly  good  grinding  surfaces  are  formed  on  the  anterior 
teeth,  which  are  very  useful  when  the  bicuspids  and  molars  are  lost. 
In  most  individuals  the  edges  of  the  lower  incisors  are  slightly  over- 
lapped by  those  of  the  upper,  which  gives  them  a  scissors  action.  The 
crowns  of  the  upper  central  incisors  are  wider  than  the  lower,  with  the 
result  that  every  tooth  in  the  lower  jaw,  with  the  exception  of  the  cen- 
tral incisors,  is  in  relation  with  two  teeth  in  the  upper,  and  every  tooth 
in  the  upper  jaw,  except  the  last  molar,  is  in  relation  with  two  in  the 
lower.  This  relation  is  in  such  a  way  that  any  cusp  of  any  tooth  in 
the  lower  jaw  is  slightly  in  advance  of  the  corresponding  cusp  of  the 
same  tooth  above  (Fig.  8).     In  the  molar  region  the  buccal  cusps  of 


16  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  lower  teeth  rest  in  the  grooves  formed  between  the  buccal  and 
lingual  cusps  of  the  upper.  Any  variation  from  this  arrangement  in 
the  child,  especially  if  the  variation  is  in  the  occlusion  of  the  first 
molars,  should  be  referred  to  the  orthodontist  for  examination. 

The  crowns  of  the  teeth  may  be  perfectly  formed,  or  show  the  mal- 
formations resulting  from  early  nutritional  disturbances.  Common 
among  these  is  the  Hutchinson  tooth,  which  is  best  marked  in  the  upper 
central  incisors,  and  consists  in  a  notching  of  the  incisal  edge  and  a 
globular  shape  to  the  crown.  This  has  been  supposed  to  be  almost 
always  caused  by  congenital  syphilis.  The  crowns  of  the  teeth  may  be 
of  various  sizes  and  shades  of  color,  and  the  teeth  may  vary  in  form 
and  number.  They  may  be  abnormally  soft,  and  as  a  result  of  this  in 
young  people,  or  from  continued  use  in  older  ones,  the  crowns  may 
be  worn  away  almost  to  their  necks.  The  teeth  may  present  all 
stages  of  caries  from  slight  pits  in  the  enamel  to  total  destruction  of 
the  crowns  and  parts  of  the  roots.  In  most  instances  the  caries  is  evi- 
dent on  ordinary  inspection.  A  cavity  may,  however,  be  hidden  on  the 
interdental  surface,  or  a  very  slight  crack  in  the  enamel  may  lead  down 
to  an  extensive  destruction  of  the  dentin  or  to  an  open  pulp  cavity. 

Unless  the  patient  is  scrupulous  in  the  care  of  his  teeth,  and  even 
then  in  certain  individuals,  the  teeth  will  show  deposits  of  tartar.  This 
consists  mostly  of  the  precipitated  calcium  salts  of  the  saliva,  and 
therefore  the  deposits  will  be  greatest  on  the  lingual  surfaces  of  the 
lower  incisors  and  canines  and  on  the  buccal  surfaces  of  the  upper 
molars,  these  being  exposed  to  the  salivary  streams  from  the  submax- 
illary, sublingual,  and  parotid  glands. 

The  nerves  supplying  the  teeth  are  derived  from  the  second  and 
third  divisions  of  the  fifth  nerve,  the  dental  branches  from  which  pass 
through  bony  canals  in  the  substance  of  the  maxilla  and  the  mandible. 
They  also  receive  fibers  from  the  palatal,  lingual,  and  buccal  nerves. 
Caries  or  other  irritations  of  the  teeth,  or  direct  irritation  of  the  nerves 
in  the  bony  canals,  may  cause  reflex  neuralgia  along  other  distributions 
of  the  fifth  nerve.  It  may  also  cause  spasm  of  the  muscles  of  mastica- 
tion. Spasm  seems  to  be  more  commonly  associated  with  irritation  of 
the  third  division  than  of  the  second. 

In  this  regard,  the  condition  of  the  tooth  pulp — whether  healthy,  in- 
flamed, or  dead — and  the  condition  of  the  peridental  membrane  is  often 
a  matter  of  importance. 

The  diagnosis  of  the  conditions  of  a  tooth  depends  on  changes 
of  color,  sensitiveness  or  lack  of  sensitiveness  to  certain  stimuli,  includ- 
ing the  electric  current,  heat  and  cold,  variations  in  translucency,  and 
percussion  note  produced  when  struck  with  a  metal  instrument.  To 
interpret  these  accurately  requires  the  experience  and  training  that  be- 


ANATOMICAL  CONSIDERATIONS.  it 

long  essentially  to  the  dentist.  The  most  accurate'  method  of  diagno- 
sing the  condition  of  the  pulp  is  by  the  use  of  the  electric  current  as 
developed  by  Prinz.^ 

GUMS. 

The  gums  may  be  inspected  and  palpated  throughout  their  entire 
extent.  They  are  composed  of  a  mucoperiosteum,  which  surmounts 
the  alveolar  processes  of  the  jaws.  This  covering  resembles  the  soft 
tissue  of  the  hard  palate,  and  contains  large  mucous  glands.  These  are 
especially  numerous  near  the  necks  of  the  teeth,  and  any  of  them  may 
give  origin  to  mucous  cysts.  It  is  continuous  with  the  mucous  covering 
of  the  lips  and  cheeks  on  the  outer  surface,  and  with  that  of  the  palate 
and  floor  of  the  mouth  on  the  inner.  Around  each  tooth  the  muco- 
fibrous  tissue  rises  on  the  base  of  the  crown,  forming  a  collar  which 
constitutes  the  gingival  margin.  P'or  some  distance  from  its  occlusal 
edges,  each  tooth  is  in  contact  with  the  tooth  on  either  side  of  it. 
Toward  the  neck  the  crown  decreases  in  size,  leaving  the  inter- 
dental spaces  into  which  the  gingiva  extends,  forming  the  interdental 
papilla.  The  periosteum  descends  into  the  alveolus  as  the  peridental 
membrane,  which  performs  its  double  role  of  covering  the  root  and  lin- 
ing the  socket. 

The  peridental  membrane  is  of  such  consistency  that,  while  it  holds 
the  teeth  sufficiently  firm  for  function,  they  are  not  perfectly  rigid  in 
their  sockets,  and  an  inflammation  of  this  membrane  will  cause  the 
teeth  to  rise  and  become  abnormally  loose. 

Salivary  calculus,  which  collects  around  the  necks  of  the  teeth,  is 
one  of  the  causes  of  chronic  irritation  of  the  gingiva,  and  brings  about 
the  recession  of  the  gums  so  commonly  seen.  This  irritation  may  open 
an  avenue  of  infection  to  the  peridental  membrane,  in  which  case  pus 
may  be  seen  exuding  from  between  the  socket  and  root,  and  the  teeth 
may  become  permanently  loosened  and  lost.  When  advanced,  this  con- 
dition is  called  pyorrhea  alveolaris,  and  is  to  be  distinguished  from  an 
abscess  in  connection  with  the  root,  which  discharges  between  the  tooth 
and  the  soft  tissue.  Certain  mineral  poisons  also  predispose  the  gingiva 
to  ulcerative  inflammation,  among  which  are  mercury,  phosphorus,  and 
bismuth,  while  lead  produces  the  characteristic  blue  line  running  along 
the  gingival  edge. 

After  an  unchecked  caries  has  attacked  the  dentin  of  the  crown,  it 
is  apt  to  open  into  the  pulp  chamber,  which  is  continuous  with  the  root 
canal.  This  later  opens  through  the  apical  foramen  into  the  apical  con- 
nective tissue  space  of  the  alveolus,  creating  an  open  avenue  of  infec- 
tion from  the  pulp  chamber  to  the  peridental  tissue,  which  may  result 
in  any  degree  of  inflammation  or  suppuration. 

2  Prinz,  Dental  Materia  Medica,  page  585. 


18  SURGERY  OF  THE  MOUTH  AND  JAWS. 

If  properly  treated  by  the  dentist,  such  an  abscess  may  sometimes 
be  made  to  discharge  through  the  root  canal,  but  if  neglected,  it  seeks 
the  surface  by  one  or  two  routes.  In  the  incisor  region  it  may  occa- 
sionally discharge  at  the  side  of  the  root,  so  that  the  pus  will  be  seen 
welling  up  around  the  neck.  In  all  cases  it  will  most  likely  perforate 
the  alveolar  process,  and  give  rise  to  a  subperiosteal  abscess,  which 
occasionally  points  toward  the  mouth,  but  generally  toward  the  buccal 
cavity.  In  the  upper  jaw  such  an  abscess,  having  perforated  the  bone, 
may  burrow  under  the  mucous  membrane  of  or  perforate  into  the  max- 
illary sinus.  Such  abscesses  are  generally  accompanied  by  consider- 
able swelling  of  the  face  and  marked  constitutional  disturbance.  The 
acute  pain  is,  for  a  time  at  least,  relieved  when  the  pus  finds  egress 
from  the  alveolus. 

If  the  perforation  is  from  the  abscess  surrounding  the  root  of  a 
tooth  that  has  but  a  single  root,  as  an  incisor,  it  will  almost  always 
be  on  the  labial  surface  of  the  alveolar  process.  In  the  case  of  a  lower 
molar — which  has  two  roots,  one  in  front  of  the  other — the  perforation 
may  be  on  either  surface,  usually  the  buccal.  The  first  and  second 
upper  molars,  however,  have  each  three  roots,  one  large  one  on  the 
palate  side  and  two  smaller  ones  situated  buccally.  Infection  from  the 
tooth  may  travel  through  any  of  these  roots,  and  therefore  the  perfora- 
tion of  such  an  abscess  may  be  into  the  antrum  or  on  the  palate,  or  the 
buccal  surface.  In  any  event,  the  resulting  abscess  may  be  present  at 
the  time  of  the  examination,  or  a  sinus  may  lead  down  to  a  piece  of 
dead  bone  or  root,  or  to  a  chronic  bone  abscess. 

In  the  lower  jaw  the  dissecting  up  of  the  periosteum  by  pus  is  apt 
to  be  followed  by  extensive  necrosis  of  the  bone,  but  in  the  upper  jaw 
caries  or  absorption  abscess  is  more  common.  The  presence  of  areas 
of  necrotic  bone  may  be  verified  by  feeling  with  an  ordinary  probe,  but 
caries  is  best  detected  by  thrusting  a  sharp  steel  Gilmer  probe  through 
the  gum  tissue  into  the  soft  insensitive  bone,  or  by  use  of  the  x-ray. 
Though  the  mucous  covering  of  the  gum  is  relatively  rather  insensi- 
tive, it  is  better  to  cocainize  it  before  making  the  punctures.  A  local 
tenderness,  a  submucous  thickening,  or  an  abnormally  soft  spot  will 
generally  be  the  guide  for  making  such  a  puncture.  In  any  of  these 
conditions  a  radiogram  is  very  helpful. 

The  gums  may  be  the  seat  of  leucoplakia,  acute  or  chronic  abscess, 
or  mucous  cysts.  Very  rarely  in  young  people  there  is  a  chronic  hyper- 
trophy of  the  gums  that  may  hide  the  teeth  and  greatly  encroach  upon 
the  vestibule  and  mouth  cavity   (Fig.  363). 

Epulis  may  be  present  on  the  gums  in  the  form  of  a  small  peduncu- 
lated or  sessile  tumor  arising  from  the  peridental  membrane  or  perios- 
teum ;  or  a  sarcoma,  osteoma,  or  fibroma  may  involve  a  large  section  of 


ANATOMICAL  CONSIDERATIONS.  19 

the  gum   and   jaw-bone.     Carcinoma,    often   secondary    to    carcinoma 
of  the  Hp,  cheek,  or  tongue,  is  common  in  old  people,  especially  men. 

VESTIBULE  OF  THE  MOUTH. 

The  vestibule  of  the  mouth  is  the  space  bounded  by  the  lips  and 
cheeks  externally,  and  the  teeth  and  gums  internally.  The  muscular 
layer  of  the  cheeks  and  lips  is  more  or  less  closely  attached  to  the  outer 
surface  of  the  jaws.  The  mucous  lining  is  reflected  on  the  alveolar 
processes,  and  is  continuous  with  the  gums.  In  the  midline  above,  this 
reflection  is  drawn  down  in  a  fold  which  connects  the  upper  lip  with 
the  gum.  This  fold,  which  is  called  the  frenum  or  frenulum  of  the  lip, 
may  contain  a  nodule  or  may  preserve  the  infantile  arrangement  of 
reaching  to  the  incisive  papilla.  In  the  latter  case  it  will  cause  a  sepa- 
ration of  the  two  central  incisors.  The  frenum  of  the  lower  lip  is  not 
so  marked  as  the  upper. 

Posteriorly,  when  the  mouth  is  closed,  there  is  a  space  behind  the 
third  molars  and  the  maxillary  tubercle,  that  will  admit  a  5-millimeter 
tube,  through  which  the  vestibule  communicates  with  the  cavity.  When 
the  mouth  is  widely  open,  the  pterygomaxillary  ligament  can  be  felt 
stretching  from  the  hamular  process  of  the  sphenoid  bone  to  the  inner 
side  of  the  ramus  of  the  mandible.  Posteriorly  the  superior  constrictor 
of  the  pharynx  is  attached  to  the  full  length  of  the  ligament,  while  an- 
teriorly it  gives  attachment  to  the  buccinator  muscle,  and  through  it 
these  muscles  are  continuous  with  each  other.  The  orbicularis  oris 
muscle  in  front,  the  buccinators  laterally,  and  the  superior  pharyngeal 
constrictor  behind  form  a  continuous  muscular  band  which  surrounds 
the  vestibule  and  the  oral  pharynx.  To  the  outer  side  of  this  ligament 
may  be  felt,  in  the  order  named,  the  anterior  border  of  the  internal 
pterygoid  muscle,  the  whole  of  the  anterior  of  the  border  of  the  ramus 
of  the  mandible  and  its  coronoid  process,  and  the  anterior  border  of 
the  masseter  muscle    (Fig.  260). 

Temporal  abscess  may  point  into  the  upper  fornix  of  the  vestibule, 
between  the  coronoid  process  and  the  maxillary  tubercle.  In  the  upper 
fornix  above  the  first  molar  may  be  felt  the  prominence  of  the  malar 
process  of  the  maxilla.  In  front  of  this  prominence  is  the  canine  fossa, 
through  which  the  antrum  may  be  opened.  'Opposite  the  second  molar 
tooth  will  be  seen  the  papilla  through  which  the  duct  of  the  parotid 
gland  discharges.  It  admits  a  probe  with  difficulty.  The  cheeks  and 
lips  are  everywhere  closely  applied  to  the  gums  and  teeth  by  the  tone 
of  the  buccinator  muscle,  which,  in  chewing,  prevents  the  food  from 
falling  into  the  lower  fornix.  In  palsy  of  the  seventh  nerve  this  power 
is  lost. 

The  mucous  membrane  is  everywhere  closely  adherent  to  the  mus- 


20  SURGERY  OF  THE  MOUTH  AND  JAWS. 

cles  of  the  cheeks,  with  but  httle  submucous  tissue.     This  accounts  for 
the  fact  that  in  heaUh  it  is  seldom  caught  between  the  teeth. 

There  are  a  number  of  mucous  glands  lining  the  cheek,  especially  in 
the  neighborhood  of  the  last  molar  teeth,  which  are  called  the  buccal 
glands.  These  may  become  cystic.  Over  the  lips  the  submucous  tissue 
contains  a  number  of  large  mucous  glands,  which  may  be  felt  with  the 
tongue,  and  which  may  be  congenitally  cystic  or  may  become  distended 
later.  The  cheek  may  present  an  acute  or  chronic  traumatic  ulcer,  a 
papilloma,  a  patch  of  leucoplakia,  or  a  carcinoma.  Sarcoma  of  the 
cheek  may  be  secondary  to  sarcoma  of  the  jaw.  The  gums,  lips,  and 
cheeks  may  show  recent  noma  or  its  resulting  scars.  Dense  scars 
from  this  or  other  causes,  situated  in  the  oral  surface  of  the  cheek,  may 
materially  limit  the  separation  of  the  jaws. 

LIPS. 

The  lips  surround  the  entrance  to  the  vestibule,  which  is  the  rima 
oris.  Here  they  are  covered  with  a  modified  mucous  membrane,  which 
begins  where  the  integument  changes  color  at  the  outer  margin.  This 
membrane  ends  posteriorly  just  behind  the  line  along  which  they  meet 
when  closed,  where  it  merges  into  the  ordinary  mucous  membrane  of 
the  vestibule.  It  contains  numerous  simple  vascular  papillae,  in  which 
its  nerves  terminate,  and  which  renders  this  part  of  the  lip  exquisitely 
sensitive  to  pain.  It  contains  no  hair  follicles,  but  especially  near  the 
skin  line  are  numerous  sebaceous  follicles,  which  may  become  the  seat 
of  minute  retention  cysts,  or  the  starting  point  of  rodent  ulcer.  The  lips 
themselves  are  made  up  of  skin,  fatty  superficial  fascia,  the  orbicularis 
oris  muscle,  submucous  tissue,  and  mucous  membrane.  The  two  lips 
converge  at  the  angles  of  the  mouth,  which  are  situated  opposite  the 
first  bicuspid  teeth.  The  line  of  closure  of  the  lips  is  slightly  curved, 
and  iis  just  below  the  middle  of  the  upper  incisor  crowns.  The  size  of 
the  rima  oris  varies  in  individuals,  and  seems  to  be  related  to  the  size 
and  prominence  of  the  teeth. 

The  orbicularis  oris,  which  surrounds  the  aperture,  is  a  circular 
muscle,  which  has  very  slight  bony  connections,  but  is  closely  attached 
to  both  the  mucous  membrane  and  the  skin.  It  receives  fibers  from  and 
constitutes  the  insertion  of  every  muscle  of  the  face  that  converges  to 
the  mouth,  including  the  buccinators,  and  accounts  for  the  infinite 
variety  of  expressions  and  contortions  of  which  the  lips  are  capable. 
The  laxity  of  the  lips  favors  plastic  operations,  but  is  also  partly  re- 
sponsible for  the  distortion  caused  by  scars  that  follow  destructive  in- 
flammations. The  lips  contain  a  large  amount  of  connective  tissue,  and 
are  capable  of  immense  swelling  that  may  be  dependent  on  injury,  in- 
fection, or  angioneurotic  edema. 


ANATOMICAL  CONSIDERATIONS.  21 

The  blood  swpply  of  the  Hps  is  mostly  from  the  coronary  arteries, 
which  form  an  elliptical  anastomosis  around  the  mouth  near  the  deep 
surface,  and  which  can  usually  be  felt  pulsating  under  the  mucous 
membrane.  In  falls  on  the  lips,  they  are  easily  cut  by  the  teeth,  and 
the  blood  may  be  swallowed,  thus  giving  rise  to  the  surmise  of  some 
internal  injury.  The  facial  vein  continues  above  with  the  ophthalmic, 
and  neither  contain  valves,  which  accounts  for  the  comparative  fre- 
quency with  which  facial  infections  cause  septic  thrombosis  of  the 
cavernous  sinuses.  The  cutaneous  surface  of  the  lips  in  both  sexes  is 
closely  beset  with  hair  follicles,  that  may  become  the  starting  point  of 
carbuncle.  The  lymphatics  of  the  lip  drain  into  the  submental  and  sub- 
maxillary nodes.  The  sensory  supply  is  of  the  fifth  nerve — the  upper 
lip  through  the  infraorbital,  the  lower  through  the  long  buccal  and  in- 
ferior dental.  The  motor  supply  of  all  the  muscles  of  the  face  is  from 
the  seventh  cranial  nerve.  Complete  unilateral  paralysis  causes  a  char- 
acteristic drawing  of  the  mouth  to  the  opposite  side  and  inability  to 
close  the  eye. 

The  lips  and  oral  slit  are  subject  to  a  variety  of  malformations. 
The  lower  lip  especially  may  be  subject  to  congenital  enlargement  due  to 
lymphatic  hypertrophy.  There  may  be  enlargement  of  the  upper  lip  in 
children,  associated  with  labial  fissures.  In  both  children  and  adults 
enlargement  of  the  lower  lip  may  be  due  to  syphilis.  The  skin  of  the 
lips  immediately  surrounding  the  mouth  may  be  covered  with  fine  radi- 
ating scars  of  syphilitic  origin.  The  lips  are  the  common  seat  of  nevi 
of  various  sizes,  and  the  mucocutaneous  edge  of  the  lip  is  the  most  com- 
mon site  of  herpes,  fissure,  extragenital  chancre,  and  epithelioma. 
Papillomata  of  the  lip  have  been  known  to  become  cornified,  and  even  to 
develop  true  protruding  horn.     Either  lip  may  be  congenitally  cleft. 

TEMPOROMANDIBULAR  JOINT. 

Passing  the  finger  backward  along  the  lower  border  of  the  zygoma, 
the  condyle  of  the  mandible  is  distinctly  palpable  just  in  front  of  the 
ear.  Pressing  gently  on  this  point  with  two  fingers  while  the  mouth 
is  being  opened,  the  condyle  is  felt  to  travel  first  downward  and  for- 
ward, and  then  straight  forward  as  it  travels  on  and  then  across  the 
articular  eminence.  As  the  limit  of  excursion  is  approached,  there 
may  be  a  slight  click,  a  loud  cracking,  or  even  a  locking  of  the  condyle 
on  the  eminence.  The  latter  is  a  subluxation.  The  condyle  may  be 
dislocated  into  the  pterygoid  fossa,  in  which  event  the  mouth  is  held 
rigidly  open.  When  the  mouth  is  wide  open,  a  deep  hollow  can  be 
felt  in  "the  position  that  is  occupied  by  the  condyle  when  the  mouth  is 
closed.  Ey  violent  force  transmitted  through  the  jaw,  such  as  a  fall 
on  the  chin,  the  condyle  may  be  driven  through  the  tympanic  plate  of 


22  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  temporal  bone  into  the  middle  ear  or  upward  into  the  middle  fossa 
of  the  skull,  constituting  the  backward  or  upward  dislocations. 

This  joint,  on  one  or  both  sides,  may  be  replaced  by  a  true  ankylosis, 
or  the  movement  may  be  limited  by  fibrous  tissue.  If  ankylosis  has  ex- 
isted during  the  period  of  growth,  it  will  interfere  with  the  develop- 
ment of  the  mandible  and  cause  retraction  of  the  chin.  The  joint  may 
be  the  seat  of  any  of  the  affections  to  which  true  joints  are  subject. 
Suppuration  in  the  joint  is  more  apt  to  spread  anteriorly  or  posteriorly 
than  externally  or  medially  on  account  of  the  relative  thickness  of  the 
capsule  in  these  various  surfaces.  On  account  of  its  proximity  to  the 
middle  ear,  the  pus  may  invade  that  cavity,  or  vice  versa. 

There  may  be  mechanical  interference  with  normal  action  of  the 
jaw,  or  there  may  be  paralysis  or  spasticity  of  one  muscle  or  a  group  of 
muscles,  or  certain  members  of  several  groups.  The  former  condition 
may  be  due  to  one  or  more  of  several  causes.  A  tumor  may  mechanic- 
ally interfere,  or  the  joint  may  be  the  seat  of  true  or  fibrous  ankylosis, 
or  of  exostosis.  The  condyle  or  interarticular  cartilage  may  be  dislo- 
cated, or  scars  may  bind  the  bone  in  any  part.  In  certain  fractures  the 
jaws  cannot  close  voluntarily.  The  limitation  may  be  voluntary,  to 
avoid  the  pain  it  would  induce  as  the  result  of  inflammation  or  an  in- 
jury. Muscle  spasm  may  be  caused  by  central  irritation  or  peripheral 
irritation  along  the  distribution  of  its  own  or  associated  nerves ;  almost 
never  by  disease  within  the  muscle.  Paralysis  is  always  caused  either 
by  a  central  lesion  or  some  interference  in  the  course  of  the  motor-con- 
ducting paths  to  that  muscle. 

JAWS. 

The  jaws  should  be  examined  on  all  exposed  surfaces.  With  the 
exception  of  the  sigmoid  notch,  all  of  the  borders  and  most  of  the  sur 
faces  of  the  mandible  may  be  palpated.  The  maxillae,  with  the  malar 
bones,  are  almost  equally  accessible  to  the  examining  fingers.  In  seek- 
ing for  obscure  fractures,  care  should  be  taken  not  to  increase  the 
original  damage  in  the  effort  to  obtain  crepitation.  Gentle  manipula- 
tion is  all  that  is  ever  permissible,  and  is  usually  sufficient.  Pressure 
applied  at  the  angles  will  cause  pain  at  a  fracture,  and  such  a  hint 
should  be  sufficient. 

The  portion  of  the  alveolar  process  may  be  broken  from  either  jaw. 
Fractures  of  the  maxillae  are  usually  impacted,  and  crepitus  is  rarely 
present.  One  maxilla  may  be  broken  loose,  or  there  may  be  a  complete 
transverse  fracture  through  both  bones,  so  that  the  upper  jaw  hangs 
from  the  cranial  base  only  by  the  soft  tissues.  Fractures  of  the  maxillae 
may  extend  into  the  oral,  orbital,  or  nasal  cavities,  or  into  the  maxillary 
antrum,  or  may  injure  the  superior  maxillary  nerve,  the  nasal  duct,  or 


ANATOMICAL  CONSIDERATIONS.  23 

branches  of  the  internal  maxillary  artery.  Through  its  intimate  asso- 
ciations with  the  nasal  passage  and  accessory  cavities,  fractures  of  the 
maxilla  may  be  followed  by  emphysema  of  the  cellular  tissues  of  the 
face. 

With  advancing  age,  as  the  teeth  are  lost,  the  alveolar  processes  are 
absorbed;  when  entirely  gone,  plates  for  artificial  teeth  are  worn  with 
difficulty.  As  their  function  is  lost,  the  muscles  of  mastication  atrophy, 
and  with  them  the  bone  that  serves  for  their  attachment,  so  that  the 
angle  of  the  jaw  appears  to  gradually  open  out  and  the  body  to  lengthen. 
Loss  of  teeth  and  alveolar  processes  gives  the  peculiar  shortening  of 
the  lower  part  of  the  face  and  the  prominence  of  the  chin  often  seen 
in  old  people. 

The  jaws  may  present  deformity  resulting  from  maldevelopment, 
necrosis,  or  malunion  of  fracture,  and  are  subject  to  a  variety  of  cysts 
and  tumors. 

Among  the  tumors  of  the  upper  jaw  are  fibroma,  enchondroma, 
osteoma,  myeloid  sarcoma,  round-  or  spindle-celled  sarcoma,  and  can- 
cer. The  last  is  secondary,  usually  to  cancer  of  the  mucous  mem- 
brane of  the  mouth  or  antrum.  In  the  upper  jaw,  mucous  cysis  of  the 
antrum  and  dental  cysts  are  the  varieties  usually  found.  The  lower 
jaw  is  subject  to  the  same  tumors  as  the  upper,  but  myeloid  sarcoma  is 
much  more  common.  The  common  cyst  of  the  lower  jaw  is  a  dentiger- 
ous  cyst,  while  fibrocystic  tumors  also  hold  this  as  their  site  of  election. 
Actinomycosis  is  commonest  in  the  neighborhood  of  the  lower  jaw,  and 
both  jaws  may  be  involved  in  leontiasis  ossea. 

Fractures  of  the  mandible  are  not  impacted,  and  those  of  the  body 
are  usually  compound,  owing  to  the  inelastic  character  of  the  muco- 
periosteum  covering  the  gums.  We  have  seen  one  impacted  fracture 
of  the  mandible,  but  regard  it  as  a  surgical  curiosity. 

Maxillary  Antrum. — The  maxillary  antrum  is  situated  in  the 
body  of  the  maxilla.  The  upper  wall  of  the  antrum  is  the  floor  of 
the  orbit,  the  inner  wall  is  part  of  the  outer  wall  of  the  nasal  fossa,  the 
outer  wall  is  the  facial  surface  of  the  maxillary  bone,  and  the  inferior 
wall  is  the  base  of  the  alveolar  process.  It  communicates  through  a 
small  opening  in  the  hiatus  semilunaris  with  the  middle  meatus  of  the 
nose.  This  opening  is  at  the  upper  part  of  the  antral  cavity,  and  free 
fluid,  usually  pus,  can  drain  through  this  opening  only  when  the  head 
is  held  downward  or  to  the  opposite  side.  The  infraorbital  nerve  runs 
in  the  upper  wall  of  the  antrum,  and  its  anterior  and  middle  dental 
branches  course  downward  in  canals  in  the  outer  wall.  The  nasal  duct, 
which  conducts  the  tears  from  the  lacrymal  sack  to  the  inferior  meatus 
of  the  nose,  runs  through  its  inner  wall.  The  apices  of  the  roots  of 
the  molar  teeth,  of  one  or  both  of  the  bicuspid  teeth,  and  sometimes  of 


S4  -SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  cuspid  tooth,  are  in  close  relation  with  its  floor  and  may  extend  up 
into  the  cavity.  Malignant  growths  tend  to  infiltrate  through  the  wall, 
while  cysts  and  benign  tumors  may  thin  the  wall  and  push  it  outward. 
Cysts  may  arise  from  the  mucous  glands  of  the  interior,  or  may  be  the 
extension  upward  of  dental  cysts — rarely  dentigerous  cysts.  The  outer 
wall  may  become  so  thinned  that  digital  pressure  will  cause  a  crackling, 
or  fluctuation  may  be  felt.  Aspiration  or  puncture  of  the  antrum  is 
done  through  the  inferior  meatus  of  the  nose,  the  canine  fossa,  or, 
when  a  suitable  tooth  has  been  recently  extracted,  through  the  alveolus. 
The  antrum  may  be  examined  by  palpation,  transmitted  light,  x-ray, 
aspiration,  and  exploration.  Infection  from  the  roots  of  the  teeth  in 
relation  to  it  may  cause  suppuration  between  the  mucoperiosteal  lining 
and  the  bony  wall,  may  infect  the  mucous  cavity  directly,  or  may  even 
cause  infection  of  the  orbit  (Figs.  290,  300). 

Tumors  that  arise  in  the  antrum  may  grow  in  any  direction.  When 
inward,  they  obstruct  the  nose  and  the  nasal  duct;  inward  and  back- 
ward, they  obstruct  the  nasopharynx;  upward,  they  infringe  on  the 
orbit,  causing  exophthalmus  and  neuralgia ;  outward,  they  cause  swell- 
ing of  the  face,  with  neuralgia ;  and  downward,  cause  downward  arch- 
ing of  the  palate,  loosening  of  the  teeth,  and  toothache. 

MUSCLES  OF  MASTICATION. 

When  tense,  the  masseter  muscle  can  be  distinctly  felt,  and  often 
seen,  on  the  outer  surface  of  the  ramus.  The  temporal  muscle  can  be 
felt  while  chewing,  and  by  pressing  with  the  finger  just  above  and  in 
front  of  the  ear.  As  mentioned,  the  anterior  border  of  the  internal 
pterygoid  can  be  felt  in  the  mouth,  but  the  external  pterygoid  muscle 
cannot  be  palpated. 

In  tetanus  the  masticatory  muscles  are  usually  the  first  and  most 
constantly  involved,  but  spasm  of  these  muscles  may  result  from  intra- 
oral irritations,  especially  those  located  over  the  distribution  of  the 
third  division  of  the  fifth  nerve.     The  spasm  may  be  clonic  or  tonic. 

Paralysis  of  the  muscles  of  mastication  will  follow  any  injury  of 
the  motor  root  of  the  fifth  nerve,  and  commonly  an  operation  on  Gas- 
serian  ganglion  or  its  root  for  facial  neuralgia. 

SALIVARY  GLANDS. 

Sublingual  Gland. — The  sublingual  gland,  lying  between  the 
mylohyoid  and  the  geniohyoglossus  muscles,  and  covered  by  the  mucous 
floor  of  the  mouth,  has  already  been  noted.  It  has  a  number  of  ducts, 
and  contains  no  lymph  nodes. 

Parotid  Gland. — The  parotid,  the  largest  of  the  salivary  glands, 
lies  just  in  front  of  the  ear,  behind  and  overlapping  the  ramus  of  the 


ANATOMICAL  CONSIDERATIONS.  25 

jaw  and  masseter  muscle.  When  inflamed,  it  causes  the  swelling  that 
is  characteristic  of  mumps.  The  space  in  which  the  gland  lies  is  in- 
creased when  the  head  is  held  erect,  with  the  mouth  closed  and  the  jaw 
thrust  forward,  and  advantage  should  be  taken  of  this  while  making 
an  examination.  It  is  impossible  to  feel  the  substance  of  the  gland  in 
the  normal  condition.  It  seems  to  be  peculiarly  liable  to  infection  in 
some  epidemic  of  typhoid  fever,  and  may  also  become  infected  by  local 
injury,  or  through  its  duct.  The  gland  is  incased  in  a  dense  fascia 
externally  and  below;  but  internally,  at  the  upper  part,  the  sheath  is 
lacking,  and  the  parotid  space  communicates  with  the  deep  connective 
tissue  spaces  of  the  pharynx.  Retropharyngeal  abscess  may  infect  the 
gland,  or  pus  from  the  gland  may  burrow  into  the  space,  into  the  tem- 
poral fossa,  down  into  the  neck,  or  into  the  external  auditory  canal ;  but 
it  rarely  points  superficially.  Virchow  has  reported  cases  of  intra- 
cranial infection  from  parotid  abscess  along  the  branches  of  the  fifth 
nerve. 

The  duct  of  the  parotid  gland,  Stenson's  duct,  runs  through  the 
cheek  a  finger  breadth  below  the  zygoma  to  turn  toward  the  mouth  at 
the  anterior  border  of  the  masseter  muscle,  where  it  can  be  distinctly 
felt  when  the  muscle  is  made  tense. 

Besides  the  external  carotid  artery  and  external  jugular  vein,  it 
contains  the  seventh  nerve,  the  auriculotemporal  branch  of  the  fifth 
nerve,  and  filaments  from  the  great  auricular  nerve  of  the  cervical 
plexus.  Facial  paralysis  or  neuralgia  of  the  temple  or  upper  part  of  the 
anterior  surface  of  the  pinna  may  result  from  infection  or  tumors  of 
the  parotid  gland.  It  also  contains  a  number  of  lymphatic  nodules, 
which  receive  their  efferent  vessels  from  the  eyelids,  eyebrows,  root  of 
the  nose,  upper  part  of  the  cheek,  the  frontal  and  temporal  part  of  the 
scalp,  the  outer  surface  of  the  ear,  the  tympanum,  and  possibly  from  the 
mucous  membrane  of  the  nose,  the  posterior  alveolar  region  of  the 
superior  maxilla,  and  the  soft  palate.  Its  afferent  vessels  pass  into 
deep  cervical  nodes.  Tumors  of  the  parotid  are  usually  of  a  peculiar 
variety  known  as  salivary  gland  tumors.  They  arise  from  the  body  of 
the  gland  or  detached  nodules,  most  commonly  in  young  adults,  grow 
slowly  or  remain  stationary  for  years,  and  then  may  take  on  rapid  infil- 
trating growth.  Some  sarcomata  of  the  parotid  grow  rapidly  from 
the  first. 

Submaxillary  Gland. — The  submaxillary  gland  lies  under  the 
side  of  the  jaw,  in  front  of  the  angle,  and  is  inclosed  in  a  complete 
capsule.  Part  of  the  posterior  end  of  the  gland  turns  around  the  pos- 
terior border  of  the  mylohyoid  muscle  and  lies  in  the  floor  of  the 
mouth,  and  it  is  from  this  part  that  the  duct  is  given  off.  Unless  there 
is  too  much  subcutaneous  fat,  the  normal  gland  can  usually  be  palpated 


26  SURGERY  OF  THE  MOUTH  AND  JAWS. 

by  feeling  in  the  floor  of  the  mouth  with  one  finger  while  the  gland  is 
pressed  up  from  below  with  the  other  hand.  The  facial  artery  grooves 
its  deep  surface.  While  the  vein  crosses  superficially,  its  sheath  con- 
tains lymph  nodes — usually  only  the  superficial  layer.  These  receive 
lymphatics  from  the  lips,  middle  of  the  dorsum  of  the  tongue,  and  the 
floor  of  the  mouth,  and  are  sometimes  the  secondary  starting  point  of 
a  fulminating  infection  in  the  neck — Ludwig's  angina.  Primary 
growths  of  the  submaxillary  are  rarer  than  in  the  parotid,  but  stone  in 
its  duct,  with  secondary  inflammation  of  the  gland,  is  very  much  more 
common. 

LYMPH  NODES. 

The  lymph  nodes  are  always  of  interest.  It  is  comparatively 
seldom  that  they  are  the  seat  of  primary  disease.  Secondary  enlarge- 
ment, however,  almost  constantly  follows  infections  of  the  areas  which 
they  guard,  and  they  form  the  first  barrier  to  infectious  material  that 
has  escaped  into  their  lymph  streams. 

The  lymph  nodes  that  concern  the  mouth  and  upper  part  of  the 
pharynx  are  grouped  as  follows : 

The  lingual  nodes  lie  between  the  geniohyoglossi  muscles  above  the 
mylohyoid.     They  are  small  and  rarely  palpable. 

The  suprahyoid  or  submental  lymph  nodes  are  situated  in  the  an- 
terior part  of  the  digastric  triangle,  below  the  chin  and  above  the  hyoid 
bone.  They  are  apt  to  become  enlarged  in  disease  of  the  tip  of  the 
tongue,  the  midpart  of  the  gums  or  floor  of  the  mouth,  the  midpart  of 
the  lower  lip  or  chin.  They  send  their  lymph  partly  into  the  submax- 
illary nodes  and  partly  into  a  node  situated  on  the  anterior  surface  of 
the  internal  jugular  vein,  at  the  level  of  the  cricoid  cartilage.  The  in- 
frahyoid nodes  lie  in  front  of  the  internal  jugular  vein,  between  it  and 
the  omohyoid  muscle,  just  above  the  point  where  this  muscle  crosses 
the  carotid  sheath.  They  are  supposed  to  drain  the  neighborhood  of 
the  frenum  of  the  tongue. 

The  submaxillary  group  lies  under  the  deep  cervical  fascia,  just  be- 
low the  border  of  the  mandible  on  each  side.  They  are  usually  super- 
ficial to  the  submaxillary  gland,  but  rarely  one  may  lie  beneath  it.  A 
large  node  is  usually  situated  near  the  fascial  artery.  They  receive 
streams  from  the  side  of  the  nose,  the  upper  lip,  the  outer  border  of  the 
lower  lip,  the  anterior  third  of  the  lateral  border  of  the  tongue,  the 
gums,  the  submaxillary  and  sublingual  glands,  and  the  adjacent  parts 
of  the  floor  of  the  mouth.  They  discharge  into  the  upper  deep  cervical 
nodes,  mostly  into  those  in  the  neighborhood  of  the  bifurcation  of  the 
common  carotid  artery. 

The  retropharyngeal  glands  lie  behind  the  nasopharynx,  and  re- 
ceive lymph  from  the  nasal  cavities  and  the  accessory  air  sinuses,  the 


ANATOMICAL  CONSIDERATIONS.  27 

nasopharynx,  Eijstachian  tube,  and  adjacent  structures.  Their  efferent 
vessels  run  to  the  upper  deep  cervical  glands.  From  their  position  they 
are  rarely  palpable. 

There  are  a  variable  number  of  nodes  situated  along  the  course  of 
the  internal  maxillary  artery.  These  rarely,  if  ever,  are  palpable,  and 
receive  streams  from  the  orbit,  the  zygomatic  and  temporal  fossse,  the 
cerebral  meninges,  the  nose  and  palate,  and  discharge  into  the  upper 
deep  cervical  nodes. 

There  are  a  few  nodes  in  the  superficial  fascia  of  the  cheek,  and  also 
superficial  to  the  parotid  gland.  They  drain  the  superficial  structures 
of  the  upper  part  of  the  face  and  ear,  and  empty  into  the  superficial 
and  deep  cervical  nodes.  According  to  Cunningham,  there  may  be 
present  a  lateral  nasal  node  situated  between  the  ala  of  the  nose  and  the 
cheek.     The  deep  parotid  nodes  were  described  with  the  parotid  gland. 

The  superficial  cervical  nodes  are  upon  or  imbedded  in  the  deep 
cervical  fascia  along  the  course  of  the  external  jugular  vein.  They 
drain  from  the  superficial  tissues  of  the  neck  and  the  superficial  parotid 
and  submaxillary  nodes.  The  lymph  streams  from  all  of  these  are 
emptied  into  the  deep  cervical  nodes,  which  are  arranged  in  two  groups. 
Those  along  the  common  carotid  artery  and  internal  jugular  vein,  which 
constitute  the  deep  cervical  group,  lie  under  the  sternomastoid  muscle. 
The  others,  which  are  disposed  in  the  posterior  triangle  of  the  neck 
behind  the  sternomastoid  muscle,  are  called  the  supraclavicular  group. 
They  all  finally  empty  their  lymph  streams  into  the  general  blood  stream 
at  the  junction  of  the  internal  jugular  and  subclavicular  veins. 

While  the  above  indicates  the  normal  course  of  the  lymph  streams, 
all  the  vessels  are  connected,  and  when  any  group  of  glands  and  vessels 
becomes  blocked  with  pathological  material,  the  lymph  will  seek  other 
and  more  roundabout  courses,  so  that  finally  all  the  neighboring  groups 
of  nodes  may  become  involved  from  a  single  primary  lesion. 


CHAPTER  II. 

INFLAMMATIONS,  INFECTIONS,  TUMORS,  CYSTS. 

We  are  more  resistant  to  some  infections  than  to  others — as  a  rule 
to  those  that  we  are  constantly  carrying  around  with  us.  Our  preser- 
vation from  infection  depends :  first,  on  the  fact  that  we  are  entirely 
enveloped  in  a  resisting  capsule  composed  of  skin  and  mucous  mem- 
brane ;  secondly,  on  a  more  or  less  perfectly  acquired  or  inherited 
immunity,  which,  when  efficient,  will  prevent  the  development  of  bacteria 
after  they  have  gained  access  to  our  tissues.  Sometimes  infectious  agents 
penetrate  the  skin  or  the  mucous  membrane  by  some  inherent  power 
they  possess,  and  at  other  times  they  enter  through   open  wounds. 

One  kind  of  infection  having  gained  a  foothold  often  serves  to  pave 
the  way  for  the  entrance  of  an  infection  of  another  variety.  The 
opportunities  for  invasion  are  so  numerous  that,  were  it  not  for  our 
natural  or  acquired  immunities,  and  for  the  power  that  the  tissues  have 
for  overcoming  infections  after  they  have  gained  a  foothold,  none  of 
us  would  long  survive.  Both  the  immunity  acquired  or  inherited,  which 
prevents  infection,  and  the  resistance  that  overcomes  infection  after  it 
has  occurred  are  developed  by  a  process  that  may  be  broadly  termed 
inflammation. 

INFLAMMATION. 

Inflammation  is  the  reaction  exhibited  by  live  tissues  to  irritation. 
The  irritation  may  be  mechanical,  thermal,  toxic,  chemical,  electric,  etc., 
but  to  produce  inflammation,  the  irritant  must  be  directly  or  indirectly 
continuous  in  its  action.  After  an  irritation  ceases  to  act,  the  process 
is  simply  one  of  repair.  The  inflammatory  process  and  repair  are  very 
similar  in  many  respects.  We  will  consider  that  phase  of  inflammation 
that  accompanies  an  infection.  The  changes  that  accompany  and  con- 
stitute inflammation  are  briefly  as  follows  : 

There  is,  first,  a  local  dilatation  of  the  blood  vessels,  with  an  in- 
creased supply  of  blood.  Next  follows  a  slowing  of  the  blood  current, 
with  agglutination  of  the  white  cells  to  the  walls  of  the  vessels.  There 
may  be  for  a  time  an  absolute  stoppage  of  the  blood  current  in  some  of 
the  smaller  vessels ;  accompanying  this,  there  is  a  pouring  out  of  plasma 
and  white  cells  into  the  surrounding  tissues.  In  very  severe  inflamma- 
tions even  the  red  cells  may  leave  the  vessels  without  an  apparent 
rupture  of  the  wall.     At  some  time  during  this  process  there  is  a  pro- 

28 


INFLAMMATIONS,  INFECTIONS,  TUMORS,  CYSTS.  29 

liferation  of  certain  of  the  fixed  tissue  cells.  If  the  process  advances 
sufficiently  far,  there  is  an  increase  in  the  number  of  blood  vessels.  By 
this  process,  it  will  be  understood,  the  tissues  involved  in  the  inflamma- 
tion have  increased  blood  supply  and  become  crowded  with  plasma  and 
wandering  fixed  cells,  which  form  a  resisting  wall  that  mechanically 
helps  to  keep  the  invading  infection  localized. 

Certain  of  the  white  cells  that  are  poured  out  into  the  tissues  in  an 
inflammation  have  the  power  of  devouring  invading  bacteria.  This  is 
another  factor  in  overcoming  infection,  but  the  multiplying  connective 
tissue  cells  are  much  more  resistant  to  irritants  than  are  the  leucocytes 
derived  from  the  blood.  Blood  plasma  poured  out  in  the  presence  of  an 
inflammation  has  a  much  higher  bactericidal  power  than  has  the  normal 
blood.  Even  beyond  all  this,  the  effort  to  overcome  an  invading  in- 
fection is  seldom  limited  to  a  local  inflammatory  reaction.  In  the.  first 
place,  in  the  presence  of  a  septic  infection,  there  is  an  increase  in  the 
absolute  number  and  relative  proportion  of  the  polymorphonuclear 
white  cells  of  the  blood.  Seqondly,  when  bacteria  or  bacterial  poisons 
are  absorbed  into  the  general  circulation,  there  is  a  reaction  on  the  part 
of  certain  widely  distributed  cells,  by  which  is  produced  a  specific  anti- 
body, which  directly  or  indirectly,  when  effective,  destroys  infection 
and  neutralizes  the  toxins.  From  this  it  will  be  seen  that  an  inflamma- 
tion, both  in  its  local  and  general  manifestation,  is  a  process  that  has 
for  its  object  the  overcoming  of  infection. 

The  resistance  to  a  specific  infection  is  not  immediately  lost  with 
the  subsidence  of  the  disease,  but  in  many  cases  is  permanently  re- 
tained. Thus  it  is  that  such  diseases  as  measles,  whooping-cough,  scar- 
let fever,  and  many  others  are  seldom  acquired  more  than  once  by  the 
same  individual.  This  acquired  immunity  may  even  be  handed  down 
as  an  inherited  immunity.  It  is  in  this  way  that  certain  individuals  are 
immune  to  certain  diseases  which  they  have  never  had.  In  other  in- 
stances, and  especially  with  certain  diseases,  the  immunity  is  but  short- 
lived. We  see  individuals  who  are  subject  to  recurrent  attacks  of 
pneumonia,  pus  infections,  erysipelas,  etc. 

Symptoms  of  Inflammation. — -The  classic  symptoms  of  inflam- 
mation, handed  down  from  the  time  of  Hippocrates,  are  redness,  heat, 
swelling,  and  pain.  The  redness  and  heat  are  due  to  the  increased  blood 
supply;  the  swelling,  to  the  dilatation  of  the  vessels  and  infiltration  of 
the  tissues  with  plasma  and  blood  cells,  and  in  some  instances  to  the 
increase  in  the  number  of  fixed  tissue  cells.  Pain  is  not  an  essential 
symptom  of  all  inflammations,  but  is  rather  constant  in  the  acute  stages. 
There  are  many  subacute  and  chronic  inflammations  in  which  no  pain 
occurs.  Pain  seems  to  be  due,  at  least  partially,  to  pressure;  but  it  is 
well  recognized  that  the  passive  congestion  and  edema  that  accompany 


30  SURGERY  OF  THE  MOUTH  AND  JAWS. 

an  inflammation,  to  a  certain  extent,  allay  pain.  It  is  safe  to  state  that 
the  pain  is  in  part  caused  by  the  irritant,  and  not  wholly  by  the  inflam- 
mation. 

Kinds  of  Inflammations. — An  inflammation  may  be  acute, 
chronic,  or  subacute,  but  in  all  of  its  stages  a  rigid  distinction  should 
be  made  between  the  inflammation  and  the  irritant  that  causes  it.  Until 
this  is  done,  only  confusion  can  result.  Inflammation  is  essentially  a 
protective  process,  closely  allied  to  repair  and  body  growth.  A  sub- 
acute or  chronic  inflammation  means  a  continuously  acting  irritant,  for, 
when  the  irritant  is  withdrawn  and  the  resulting  damage  repaired,  the 
inflammation  subsides.  Inflammation  is  essentially  not  an  evil,  but  an 
evidence  of  vital  resistance.  It  does  not  occur  in  dead  tissue,  and  we 
occasionally  see  instances  where  inflammation  fails  to  occur  in  tissues 
of  very  low  vitality.  Pus  formation  is  but  a  way  of  ridding  the  body 
of  the  poisons  it  cannot  neutralize. 

An  inflammation  of  any  particular  organ  or  structure  is  designated 
by  the  suflix  "itis"  or  "ia,"  as  gingivitis,  peritonitis,  glossitis,  ophthal- 
mia, and  pneumonia. 

Cellulitis  is  a  term  used  to  express  a  more  or  less  diffused  inflamma- 
tion, dependent  on  bacterial  infection,  which  travels  along  the  cellular 
tissue  planes,  particularly  those  under  the  skin,  though  it  may  occur 
between  muscles  or  in  any  part  of  the  body.  It  may  stop  short  of  or 
extend  to  suppuration.  Local  cellulitis  is  a  common  phenomenon 
around  any  suppurating  focus,  and  is  often  seen  around  a  suppurating 
focus  in  the  mouth. 

Lymphangitis  and  adenitis  refer  to  infections  spreading  in  the 
lymph  channels,  and  are  evidenced  by  an  inflammation  along  the  course 
of  the  lymphatics  and  a  swelling  of  the  lymph  nodes.  An  adenitis  may 
attain  any  stage  of  inflammation  from  acute  or  chronic  hyperplasia  to 
suppuration.  With  certain  infections,  as  the  tubercle,  the  chronic 
hyperplasia  may  be  followed  by  a  kind  of  tissue  necrosis  known  as 
caseation. 

Results  of  Inflammation. — Besides  the  overcoming  of  the  in- 
fection, certain  more  or  less  permanent  results  may  accompany  or  fol- 
low an  inflammation.  As  an  inflammation  subsides,  the  blood  vessels 
contract,  the  normal  circulation  is  restored,  and  the  plasma  and  cells 
that  have  left  the  blood  vessels  are  carried  off  in  the  lymph  streams. 
If  the  inflammation  goes  to  suppuration,  quantities  of  serum,  of  white 
cells,  and  of  fixed  tissue  cells  are  thrown  off  in  the  pus. 

Any  excess  of  connective  tissue  that  has  formed  usually  turns  into 
scar.  As  scar  tissue  ages,  it  contracts,  and  it  is  this  contraction  of 
the  interstitial  scar  tissue  that  impairs  the  function  of  the  vital  organs 
after  they  have  been  the  site  of  a  chronic  inflammation. 


INFLAMMATIONS,  INFECTIONS,  TUMORS,  CYSTS.  31 

In  an  interstkial  nephritis,  a  cirrhosis  of  the  Hver,  and  a  tabes  dorsahs 
the  parenchymatous  cells  of  the  kidney,  or  of  the  liver,  or  the  axis 
cylinders  of  certain  nerve  tracts  in  the  spinal  column  are  squeezed  until 
they  can  no  longer  perform  their  function.  Scar  formation  may  be 
long  delayed,  due  possibly  to  the  persistence  of  the  inflammation  in  a 
subacute  state.  The  surface  epithelium  may  remain  thickened  or 
changed.  In  some  instances  masses  of  new  connective  cells  will  re- 
main unchanged  for  indefinite  periods.  As  an  instance  of  this,  we  have 
the  simple  hyperplasia.  The  new  tissue  may  become  necrotic,  and 
either  liquefy  or  caseate,  and  it  sometimes  becomes  impregnated  with 
lime  salts.  We  have  examples  of  this  in  ulcerating  gummata,  or  break- 
ing-down or  calcification  of  the  tubercle.  This  fixed  tissue  cell  prolif- 
eration is  somewhat  analogous  to  tumor  formation,  which  consists 
chiefly  in  the  localized  growth  of  the  cells  of  a  certain  tissue.  Some  of 
these  localized  growths  we  know  to  be  caused  by  an  infection,  as,  for 
example,  granuloma  resulting  from  infection  with  actinomycosis.  These 
granulomata,  tubercles,  gummata,  etc.,  which  are  known  to  be  caused 
by  an  infection,  are  no  longer  classed  as  tumors.  Just  how  many  of  the 
new  growths  that  we  now  consider  to  be  true  tumors  will  be  ultimately 
classed  under  inflammatory  processes,  it  is  impossible  to  foretell 

It  might  be  argued  that  the  interstitial  scar  deposits  that  follow  some 
inflammations  are  positive  evils,  and  that  therefore  the  inflammation 
that  caused  this  scar  deposit  is  also  an  evil.  It  is,  however,  safer  to  con- 
clude that  the  inflammation  was  a  conservative  process,  and  that  the  in- 
terstitial scar  formation  is  a  lesser  evil  than  the  condition  that  would 
have  resulted  if  there  had  been  no  inflammatory  reaction.  An  inflam- 
matory granuloma  is  to  be  regarded  as  an  effort  to  hold  in  check  an 
infection  which  the  tissues  are  unable  to  destroy.  Whether  the  true 
tumors  as  we  now  regard  them  will  eventually  be  placed  in  the  same 
category,  we  do  not  know.  It  may  be  possible  that  even  the  malignant 
tumors,  such  as  cancer,  are  but  a  vain  inflammatory  effort  to  over- 
come an  infection.  Even  the  fever  that  accompanies  most  infections 
is  not  to  be  regarded  as  an  evil  per  se,.  but  as  a  necessary  part  of  the 
effort  to  overcome  infection. 

Without  negativing  this  view  of  inflammation,  it  is,  however,  prob- 
able in  many  instances  that  the  inflammatory  process  is  carried  beyond 
the  point  where  it  accomplishes  unmixed  good.  Just  as  a  fireman  may 
distribute  more  water  than  is  needed  to  extinguish  a  fire,  and  thereby 
sometimes  does  more  harm  than  the  blaze,  so  there  is  no  question  that 
stagnation  of  blood  and  lymph  in  an  inflamed  area  can  be  so  great  as 
to  cause  gangrene  by  pressure,  and  that  the  inflammation,  and  not  the 
toxins,  is  often  the  immediate  cause  of  the  localized  tissue  death.  If 
we  grant  that  inflammation  can  cause  tissue  necrosis  by  pressure,  we 


32  SURGERY  OF  THE  MOUTH  ANlD  jAWS...  .1 

will  have  also  to  grant  that  by  a  less  degree  of  pressure  the  vitality  of 
the  tissues  can  be  damaged  to  a  less  extent.  It  would  seem,  tlierefore, 
that  an  excessively  active  inflammation  can  produce  evil  results,  and 
this  idea  is  borne  out  by  the  extreme  contradictions  that  are  met  with  in 
clinical  observations. 

Gangrene  is  the  death  of  tissue,  with  putrefaction.  Necrosis  is  the 
simple  death  of  tissue.-  It  is  for  the  reason  that,  bone  being  little 
changed  by  the-  organisms  of  putrefaction,  the  death  of  bone,  even  when 
due  to  sepsis,  is  spoken  of  as  necrosis. 

Ulcer  is  the  defect  that  remains  after  a  local  surface  destruction  of 
tissue  from  bacterial  invasion,  from  the  breaking  down  of  a  tumor,  or 
following  a  number  of  different  inflammatory  processes  the  cause  of 
which  we  may  not  understand.  Any  open  sore,  whether  it  be  the  result 
of  the  bursting  of  a  herpetic  bleb ;  the  breaking  down  of  a  carcinoma, 
of  a  gumma,  or  a  tubercle;  whether  it  be  the  granulating  surface  left 
after  the  separation  of  a  superficial  slough;  an  open  sore  due  to  the 
melting  away  of  any  of  the  surface  tissues ;  or  an  open  sore  of  almost 
any  kind,  excepting  the  acute  stages  following  an  injury — any  of  these 
may  be  spoken  of  as  an  ulcer.  Naturally  the  varieties  of  ulcer  are  very 
numerous. 

INFECTIONS. 

An  infection  is  the  invasion  and  growth  of  some  kind  of  a  minute 
organism,  that  feeds  upon  and  poisons  the  living  tissues.  Agencies  of 
infection,  as  we  recognize  them,  are  various,  and  include  certain  very 
low  forms  of  life  called  bacteria,  to  which  class  belong:  the  pus-pro- 
ducing organisms,  pneumococci,  typhoid  bacilli,  etc. ;  certain  plant  cells, 
as  yeast  fungi  and  mycoses ;  and  also  some  of  the  lower  forms  of  animal 
life.  These  agencies  of  infection  are  widely  distributed.  With  some 
of  them  we  are  in  constant  touch — for  instance,  those  that  are  normally 
found  in  the  mouth  and  in  the  intestines.  With  some  other  infections 
we  rarely  come  in  contact.  As  examples  of  the  latter,  we  might  men- 
tion the  cholera  bacillus,  Bacillus  mallei  (which  causes  glanders),  the 
leprosy  bacillus,  and  Bacillus  pestis  (the  cause  of  plague). 

Spread  of  Infections. — If  an  infection  fails  to  remain  localized, 
it  may  spread  in  a  number  of  ways.  If  there  is  not  sufficient  local  re- 
sistance, infection  may  be  disseminated  along  the  neighboring  cellular 
planes,  or  it  may  spread  through  the  lymphatics,  giving  rise  to  lym- 
phangitis. If  septic  inflammation  spreads  along  the  blood  stream,  the 
condition  is  known  as  pyemia  or  septicemia,  according  to  its  mode  of 
transfer.  If  it  is  carried  to  distant  parts  of  the  body  by  means  of  small 
infected  blood  clots — septic  emboli  floating  in  the  blood  streams — the 
condition  is  known  as  pyemia.  When  such  a  clot  lodges  in  a  capillary, 
a  new  focus  of  infection  may  occur.     At  first  this  is  most  likely  to  hap- 


INFLAMMATIONS,  INFECTIONS,  TUMORS,  CYSTS.  33 

pen  in  the  capiUaries  of  the  lungs  or  hver,  and  it  is  for  this  reason  that 
pneumonia  may  follow  an  infection  of  any  part  of  the  body,  or  liver 
abscess  may  follow  an  infection  of  the  area  of  the  portal  circulation. 
Ultimately  a  pyemia  may  cause  numerous  localized  infections  in  many 
parts  of  the  body.  If  bacteria,  or  any  other  agencies  of  infection,  float 
free  in  the  blood  stream  in  any  quantity,  not  bound  up  in  blood  clots, 
the  condition  is  known  as  a  septicemia.  The  chief  difference  between 
this  condition  and  that  of  a  pyemia  is  that  in  the  latter  the  clots  con- 
taining the  bacteria  are  bound  to  lodge  in  some  small  vessel,  where  a 
secondary  focus  is  very  likely  to  arise.  Bacteria  floating  free  in  the 
blood  have  no  protection  from  the  germicidal  actien  of  the  blood,  and 
are  more  apt  to  be  destroyed. 

SUPPURATION. 

When  the  tissues  are  invaded  by  certain  organisms,  under  certain 
conditions,  suppuration  results.  Suppuration  is  characterized  by  the 
formation  of  fluid  containing  waste  material,  that  has  been  sacrificed  in 
the  struggle  against  the  invading  organisms,  together  with  dead  and 
living  microbes  and  their  products. 

It  is  preceded  by  changes  in  the  circulation  and  fixed  tissues,  already 
described  as  being  essential  parts  of  inflammatory  process,  and  is  one 
of  the  ultimate  manifestations  of  the  struggle  between  the  germs  and 
the  resisting  power  of  the  body.  In  dead  tissue  there  is  no  inflamma- 
tory action,  and  in  tissue  of  low  resistance  there  may  be  no  suppura- 
tion. 

It  was  because,  in  the  formation  of  certain  kinds  of  pus,  the  older 
surgeons  recognized  a  strong  resistance  on  the  part  of  the  body  which 
foretold  ultimate  recovery,  that  this  pus  was  referred  to  as  laudable  pus. 
Practically,  from  a  surgical  standpoint,  there  can  be  no  pus  formation 
without  the  presence  of  bacteria  of  certain  species.  Still,  pus  can  be 
produced  experimentally  by  injecting  certain  irritating  chemical  sub- 
stances. Certain  organisms  that  do  not  really  produce  pus  can  cause 
a  tissue  necrosis  that  may  liquefy  or  become  semiliquid,  but  this  is  not 
true  pus.  The  most  common  example  of  this  is  the  caseation  that  may 
take  place  in  the  granulations  that  result  from  the  presence  of  tubercle 
bacillus. 

Microorganisms  of  Suppuration. — Some  pus-forming  organisms, 
such  as  the  staphylococcus  and  Streptococcus  pyogenes,  will  always 
tend  to  form  pus.  Often,  however,  owing  to  the  lack  of  virulence  ot 
lack  of  sufficient  numbers  in  proportion  to  the  tissue  resistance,  the  in- 
flammatory process  may  be  cut  short  before  it  reaches  the  stage  of  sup- 
puration. Thus  there  may  be  a  swelling  of  the  gum  and  face  around 
an  infected  tooth,  but  this  may  subside  without  the  formation  of  pus. 


34  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Certain  infectious  organisms,  such  as  tlie  typhoid  bacilhis,  will  cause 
suppuration  only  under  extraordinary  circumstances. 

The  principal  microorganisms  of  suppuration  are  Staphylococcus 
pyogenes  aureus  and  alhus.  Streptococcus  pyogenes,  Micrococcus  gon- 
orrhooa.  Bacillus  pyocyaneus,  and  the  pneumococcus.  Among  the  or- 
ganisms that  less  commonly  cause  suppuration  are  the  typhoid  bacillus, 
influenza  bacillus,  diphtheria  bacillus,  actinomyces,  and  various  forms 
of  the  yeast  fungi.  Of  the  two  more  commonly  present  pyogenic  bac- 
teria, Staphylococcus  pyogenes  and  Streptococcus  pyogenes,  the  former 
is  usually  less  virulent,  and  is  more  easily  limited  by  the  inflammatory 
reaction  to  the  neighborhood  in  which  the  infection  occurs.  Therefore 
Staphylococcus  aureus  or  alhus  is  more  commonly  found  in  localized 
abscesses.  The  streptococcus  seems  to  be  less  easily  resisted  by  the 
inflammatory  reaction,  and  has  a  greater  faculty  of  becoming  diffused. 
It  is  therefore  more  often  the  cause  of  rapidly  spreading  extensive  in- 
fection, and  as  a  rule,  is  much  more  destructive. 

Tissue  Changes  in  Suppuration. — The  changes  in  the  tissues 
that  occur  in  suppuration  are  briefly  as  follows : 

The  changes  already  described  as  constituting  the  active  stage  of  an 
inflammation  always  occur.  The  bacteria  of  suppuration  seem  to  have 
the  power  of  attracting  from  the  blood  vessels  the  polymorphonuclear 
white  cells  in  great  numbers,  the  greater  demand  for  them  being  met 
by  a  greater  production  of  them  in  the  bone  marrow.  The  fixed  tissue 
cells  are  excited  to  greater  proliferation,  and  there  is  a  wall  of  cells 
thrown  around  and  throughout  the  inflamed  area,  derived  from  the 
fixed  tissue  cells  and  from  the  leucocytes,  that  tends  to  localize  the  in- 
fection. It  would  appear  that  around  the  staphylococcus  this  wall  is 
produced  with  comparative  ease ;  but  around  the  streptococcus  it  is  not 
easily  accomplished,  and  it  is  for  this  reason  that  one  remains  localized 
and  the  other  so  commonly  becomes  diffused. 

Owing  to  the  peptonizing  power  of  certain  bacteria,  the  tissues  in 
the  central  part  of  the  inflamed  area  become  liquefied.  As  a  result, 
there  is  a  mixture  of  blood  plasma,  dissolved  fixed  tissues,  leucocytes, 
newly  formed  cells,  bacteria,  and  poisons,  that  is  termed  pus.  An 
abscess  is  a  circumscribed  cavity  of  pathological  origin  containing  pus. 

A  collection  of  pus  in  a  closed  anatomical  cavity,  such  as  the  pleural 
cavity,  is  often  spoken  of  as  an  empyema.  If  the  infection  becomes 
localized,  the  abscess  which  contains  the  pus  is  surrounded  by  a  limiting 
wall  of  granulations.  This  wall  confines  the  pus  until  it  is  either  lib- 
erated spontaneously  by  some  tract  of  exit  formed  by  the  action  of  the 
phagocytes,  or  it  is  liberated  artificially  by  an  incision.  Less  com- 
monly the  abscess  remains  permanently  buried,  or  may  even  be  absorbed 
after  the  death  of  the  bacteria  it  contained. 


INFLAMMATIONS.  INFECTIONS,  TUMORS,  CYSTS.  35 

TREATMENT  OF  INFECTIONS  AND  INFLAMMATIONS. 

After  an  infection  has  once  gained  a  foothold  in  the  living  tissues, 
we  must  in  our  treatment  regard  not  only  the  infection  but  the  inflam- 
matory processes  that  it  has  excited.  We  are  not  certain  that  the  in- 
flammatory process  itself  ever  needs  treatment,  and  v^e  do  know  that 
there  are  very  few,  if  any,  infections  that  could  ever  be  overcome  with- 
out inflammation.  Inflammation  is  nature's  way  of  fighting  infections, 
and  we  must  work  with  it,  not  against  it;  for  otherwise  our  efforts 
will  be  in  vain. 

There  are  a  few  infections  that  we  can  overcome  by  saturating  the 
body  with  a  poison  that  will  not  destroy  the  tissues.  Among  these  may 
be  mentioned  malaria,  which  may  be  killed  by  quinin,  and  syphilis, 
which  may  be  killed  by  mercury  or  salvarsan.  When  an  infection  is 
superficial,  it  may  be  influenced  by  locally  applied  antiseptics,  such  as 
alcohol,  essential  oils,  iodoform,  silver  salts,  etc.  With  a  few  isolated 
exceptions,  however,  treatment  consists,  at  least  in  part,  in  promoting 
or  regulating  the  inflammatory  process. 

One  of  the  first  requisites  is  the  regulation  of  the  body  functions, 
especially  the  excretory  organs.  In  the  presence  of  an  infection,  the 
parenchymatous  cells  of  various  organs  may  become  sluggish  in  their 
action  and  may  require  stimulation.  The  most  common  instance  of  this 
treatment  is  the  administration  of  a  purge  and  a  stimulation  of  the 
skin  by  bathing.  Next  comes  the  establishment,  as  far  as  possible,  of 
physiological  rest  of  the  affected  part.  Nature  gives  a  strong  hint  in 
this  regard  in  the  pain  that  results  from  exercising  an  inflamed  part. 
This  rest  should  include  the  proper  quota  of  sleep,  and  it  may  be  nec- 
essary to  administer  an  analgesic  or  a  soporific.  If  the  disease  is  at  all 
prolonged,  careful  attention  must  be  given  to  the  nourishment  of  the* 
patient.  During  this  time  the  tissue  waste  is  often  greater  than  ordi- 
nary, and  the  ability  to  assimilate  food  is  lessened ;  therefore  food  should 
be  given  in  an  easily  digested  form. 

Prolonged  high  fever  is  very  detrimental,  but  it  is  not  proper  to 
continuously  give  antipyretics  to  reduce  it.  Bathing  reduces  the  fever, 
stimulates  the  secretions,  and  tends  to  quiet  nervous  irritation.  It  has 
been  a  routine  custom  to  give  alcoholic  stimulants  in  septic  infections, 
but  except  when  the  vital  functions  need  stimulating,  this  practice  is 
falling  into  disuse. 

Another  well-established  therapeutic  procedure  is,  where  anatom- 
ically possible,  to  remove  the  infection  by  a  surgical  operation.  If  the 
infected  part  is  no  longer  functional,  this  can  be  done  by  an  excision — 
as  the  surgeon  removes  an  inflamed  appendix,  and  a  dentist  removes  a 
tooth  whose  utility  cannot  be  reestablished.  In  the  presence  of  certain 
virulent  infections,  even  more  important  organs  may  be  sacrificed.     The 


36  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tongue  or  the  cervical  lymph  nodes  may  be  removed  on  account  of  a 
tubercular  infection,  and  an  arm  may  be  removed  on  account  of  a  pus, 
gas  bacillus,  or  other  virulent  infection  that  threatens  life.  A  carbuncle 
may  be  totally  excised,  and  any  but  the  absolutely  vital  organs  are  sac- 
rificed when  carcinomatous.  However,  in  many  of  our  surgical  opera- 
tions for  infection  we  are  content  with  a  less  radical  measure,  which 
consists  in  draining  the  affected  tissues  by  making  one  or  several  in- 
cisions. The  tissue  fluids  are  allowed  to  flow  out  of  the  wound,  and 
with  them  great  quantities  of  the  infecting  organisms  and  their  toxins. 
This  free  drainage  often  gives  the  fighting  tissues  just  the  help  they 
need,  and  enables  them  to  overcome  the  infection  that  remains. 

There  are  three  therapeutic  agencies,  all  of  established  value,  and 
each  contradictory  to  one  of  the  others,  which  have  to  be  mentioned,  but 
the  rationale  of  which  we  do  not  fully  understand.  These  are  heat, 
cold,  and  passive  hyperemia.  One  of  the  oldest  treatments  for  local- 
ized infection  is  heat.  In  general,  it  seems  to  promote  comfort,  allay 
pain,  and  promote  the  circulation.  With  septic  infections  it  probably 
predisposes  to  suppuration,  but  in  the  presence  of  a  septic  infection  of 
a  certain  virulency,  local  suppuration  cannot  be  regarded  as  an  evil. 
Local  irritants — counterirritants,  as  they  are  sometimes  called — act  like 
heat,  as  they  cause  a  deep  as  well  as  superficial  dilatation  of  the  blood 
vessels,  with  increased  circulation.  According  to  our  ideas,  an  in- 
creased blood  supply  means  increased  resistance. 

According  to  our  present  ideas,  it  is  rather  diflicult  to  explain  the 
good  that  undoubtedly  results  in  many  instances  from  the  application 
of  cold  to  an  inflamed  part.  It  cannot  be  from  the  direct  action  of  the 
cold  on  the  infecting  organisms,  for  they  are  generally  much  too  deep 
in  the  tissues  to  be  influenced  by  a  direct  cooling  effect.  Cold,  un- 
doubtedly, causes  a  contraction  of  the  blood  vessels,  a  lessening  of  the 
inflammatory  reaction,  and  tends  to  prevent  suppuration  and  allay  pain. 
There  are  certain  animal  experiments  that  demonstrate  the  fact  that  re- 
ducing the  temperature  of  the  tissues  reduces  their  resistance.  We 
might  conclude  that  in  all  instances  the  inflammatory  reaction  is  exces- 
sive, and  that  cold  is  beneficial  by  regulating  it.  Blood-letting  was  once 
popular,  and  in  certain  cases  it  undoubtedly  accomplishes  good.  Whether 
this  is  by  reducing  the  inflammation  or  by  stimulating  it,  or  by  drain- 
ing off  poisons,  or  by  a  combined  effort,  is  difficult  to  say.  In  apparent 
contradiction  to  this  is  the  fact  that  induced  hyperemia,  commonly 
known  as  Bier's  treatment,  increases  the  inflammatory  reaction,  and  is 
a  strong  agency  in  overcoming  infections.  Bier's  hyperemia  consists 
in  the  establishment  of  a  temporary  venous  stasis,  either  by  suction  or 
by  constricting  the  veins  above  the  inflamed  part.  This  is  an  augmenta- 
tion of  an  essential  part  of  the  inflammatory  process. 


INFLAMMATIONS,  INFECTIONS,  TUMORS,  CYSTS.  37 

There  are  two  other  plans  of  treatment  which  have  lately  demanded 
considerable  attention,  and  which  in  certain  cases  are  giving  great  re- 
sults. The  first  of  these  is  the  use  of  artificially  produced  antitoxins. 
When  an  animal  overcomes  a  disease,  it  has  circulating  in  its  blood 
antibodies  which  give  it  an  immunity  to  that  disease.  With  some  dis- 
eases this  immunity  is  permanent.  By  the  injection  of  gradually  in- 
creased doses  of  toxins  into  a  susceptible  animal,  it  is  immunized. 
When  the  blood  of  such  an  immunized  animal  is  withdrawn  and  in- 
jected into  a  similarly  infected  individual,  his  resistance  is  immediately 
increased.  The  most  brilliant  example  of  this  is  the  use  of  the  diph- 
theria antitoxin.  Unfortunately  there  are  at  present  very  few  infec- 
tions that  can  be  treated  in  this  way. 

Another  form  of  treatment,  and  one  that  promises  to  have  a  wider 
range  of  application,  is  the  artificial  stimulation  of  the  production  of 
antibodies  within  the  infected  individual.  A  localized  infection  may 
persist,  or  a  person  is  overcome  by  an  infection,  not  because  the  body 
cannot  produce  antitoxin,  but  because  it  does  not  do  so,  or  because  it 
does  not  do  so  until  the  infection  has  gained  too  great  a  headway  be- 
fore the  antitoxin-producing  reaction  has  taken  place.  As  stated  earlier 
in  this  chapter,  the  production  of  antitoxin  is  stimulated  by  the  presence 
of  toxins  in  the  general  circulation.  As  long  as  the  infection  remains 
localized,  there  may  not  be  sufficient  toxin  in  the  general  circulation 
to  call  up  this  reserve  power,  and  when  the  infection  becomes  general- 
ized, this  may  happen  so  rapidly  that  the  cells  have  not  time  to  form 
the  antibodies  before  they  are  overcome  and  destroyed  by  the  invading 
host.  It  has  been  found  that,  by  injecting  measured  doses  of  killed 
bacteria  of  the  same  strain  as  the  infection,  all  the  antitoxin-producing 
cells  of  the  body  can  be  safely  stimulated,  so  that  they  will  evolve  suffi- 
cient antitoxin  to  overcome  an  infection  while  it  still  remains  localized. 

METHOD  OF  PREPARING  AND  ADMINISTERING  AUTO- 
GENOUS VACCINES. 

By  Dr.  Charles  L.  Kxenk. 
In  order  to  produce  an  immunity  against  certain  conditions  pro- 
duced by  certain  bacteria,  one  method  is  the  use  of  a  substance  com- 
monly called  a  vaccine.  These  so-called  vaccines  are  supplied  in  stock 
form  by  various  biological  laboratories.  Preparations  are  made  from 
a  given  organism  of  a  certain  strain  or  species,  and  used  against  all 
conditions,  irrespective  of  the  strain  to  which  the  organism  belongs. 
These  "stock"  vaccines  are  in  most  instances  of  no  value,  because  it 
has  been  definitely  determined  that,  with  perhaps  the  exception  of  cer- 
tain strains  of  staphylococcus,  in  order  to  immunize  an  individual 
against  a  certain  organism  it  is  necessary  to  use  one  of  the  same  strain. 


38  SURGERY  OF  THE  MOUTH  AND  JAWS. 

This  form  of  vaccine  is  called  an  autogenous  vaccine.  The  autogenous 
vaccines  commonly  used  are  composed  of  dead  bacteria  obtained  from 
cultures,  taken  from  the  individual  to  be  immunized. 

Immunity  has  also  been  produced  by  the  injection  of  very  small 
doses  of  living  bacteria  of  full  virulence,  or  those  attenuated  by  pro- 
longed cultivation  in  vitro,  or  those  modified  by  heat. 

The  method  of  using  dead  bacteria  has  many  advantages  that  the 
others  do  not  possess.  The  dose  is  under  accurate  control — there  is  no 
danger  of  the  spread  of  the  infection,  as  might  be  the  case  if  living 
bacteria  were  used — and  the  vaccine  is  easily  kept  for  use  without  the 
danger  of  multiplication. 

The  method  of  preparing  a  vaccine  is  usually  a  simple  matter.  The 
chief  difficulty  is  to  insure  the  purity  of  the  organism  used  and  the  ab- 
sence of  all  other  bacteria,  especially  the  pathogenic  varieties.  If  possi- 
ble, a  lesion  should  be  selected  that  is  recent  and  uncontaminated.  For 
example,  in  case  of  an  abscess  the  following  is  the  procedure : 

The  skin  should  be  carefully  cleansed,  and  possibly  seared  with  a  hot 
instrument,  to  insure  the  destruction  of  all  surface  bacteria.  With  an 
absolutely  sterile  knife  or  needle  an  opening  is  made,  and  the  exuding 
pus  or  fluid  is  immediately  transferred  to  a  suitable  culture  medium  and 
incubated  for  at  least  twenty-four  hours.  The  resulting  growth  is  ex- 
amined, and  the  organism  identified.  If  a  good  culture  is  secured,  the 
growth  can  be  washed  off  the  medium  with  sterile  salt  solution  and 
put  into  a  sterile  tube.  The  number  of  bacteria  to  the  cubic  centimeter 
are  determined  preferably  by  Wright's  method.  A  certain  amount  of 
the  bacterial  emulsion  in  salt  solution  is  mixed  with  human  blood  in 
definite  proportions,  and  smears  are  prepared  over  a  strainer.  The  red 
cells  and  bacteria  are  counted,  and  the  proportion  of  the  two  will  permit 
of  the  calculation  of  the  number  of  bacteria. 

In  conditions  in  which  the  organism  is  known,  but  other  bacteria 
are  present,  it  is  necessary  to  get  rid  of  this  contamination.  Cultures 
are  usually  made  on  Petri  dishes,  or  other  containers  giving  a  large 
culture  surface.  The  writer  has  used  a  form  of  container  which  has 
been  very  useful — an  ordinary  4-  or  6-ounce  bottle,  the  so-called  flat 
Philadelphia  oval  form.  A  small  amount,  about  10  cubic  centimeters, 
of  medium  is  put  into  the  bottle,  which  is  placed  flat  on  its  broad  side. 
The  medium  is  allowed  to  solidify,  and  a  large,  smooth,  transparent 
surface  is  obtained.  After  these  cultures  are  made,  the  entire  growth 
is  worked  off  with  sterile  salt  solution.  In  some  instances  the  exact 
organism  is  not  known,  several  species  being  present  which  produce 
similar  conditions.  If  such  is  the  case,  a  vaccine  may  be  prepared  con- 
taining all  these  forms.  This  vaccine  is  known  as  "combined  vaccine." 
After  the  growths  have  been  examined  and  found  to  be  pure,  the  dose 


INFLAMMATIONS,  INFECTIONS,  TUMORS,  CYSTS.  39 

for  injection  As  determined.  The  usual  dose  for  adults  is  from  25,- 
000,000  to  50,000,000  bacteria  as  an  initial  dose.  The  kind  of  organism,, 
if  a  bacillus  or  a  coccus,  should  be  taken  into  consideration.  The  writer 
usually  begins  with  25,000,000  when  bacilli  are  used,  and  50,000,000 
when  cocci  are  used,  Wright's  method  of  counting  may  be  used  for 
this  purpose. 

The  injection  of  these  dead  bacteria  usually  produces  a  reaction, 
both  local  and  general — in  most  instances  very  mild  in  character.  The 
local  reaction  is  recognized  by  redness,  slight  swelling,  and  some  pain; 
the  general  reaction,  by  some  nausea,  pains  in  the  joint,  a  slight  eleva- 
tion of  temperature,  and  perhaps  a  slight  headache,  all  of  which  usually 
disappear  in  three  to  five  days.  This  reaction  usually  occurs  twelve  to 
twenty-four  hours  after  the  injection.  After  this  reaction  subsides, 
about  four  or  five  days  after  the  injection,  a  second  dose  is  given.  This 
dose  is  usually  twice  as  large  as  the  first,  and  is  continued  until  the 
desired  amount  is  obtained. 

A  much  simpler  method,  and  one  which  the  writer  recommends,  is 
the  determination  of  the  dose  by  the  injection  of  a  very  small  amount 
of  the  vaccine,  perhaps  two  or  three  drops,  and  if  no  reaction  occurs, 
the  dose  is  doubled  for  the  next  injection,  and  so  on  until  a  proper  re- 
action is  obtained.  This  is  then  used  as  a  basis  for  determining  the 
subsequent  injections. 

The  form  of  vaccine  in  which  the  number  of  bacteria  are  known  is 
called  "standardized,"  while  that  in  which  the  dosage  is  determined  by 
the  reaction  is  called  "unstandardized."  The  writer  secures  a  rich 
growth  on  a  large  surface  in  a  4-ounce  flat  medicine  bottle,  previously 
described,  and  washes  ofif  the  bacteria,  if  cocci,  in  10  cubic  centi- 
meters of  sterile  salt  solution ;  if  bacilli,  in  20  cubic  centimeters.  The 
emulsion  is  transferred  to  a  sterile  bottle,  and  heated  to  a  certain  tem- 
perature in  the  water  bath  to  insure  the  death  of  the  bacteria.  The  tem- 
perature must  not  be  too  high,  so  as  to  injure  their  antibactericidal 
properties.     The  usual  temperature  is  60  to  80°  C. 

The  streptococcus,  pneumococcus,  gonococcus,  and  colon  bacillus 
can  be  killed  at  60  to  65°  C.  in  one  hour.  Some  strains  of  staphylo- 
coccus will  also  be  killed  at  this  temperature.  The  writer  has  found  cer- 
tain strains  of  staphylococcus  that  require  80°  C.  for  several  hours  to 
kill  them.  The  best  results  have  been  with  the  staphylococcus,  strepto- 
coccus, and  pneumococcus.  The  colon  has  not  given  quite  as  good 
results  for  the  reason  that,  as  the  writer  believes,  the  colon  bacillus  does 
not  commonly  produce  infections,  being  a  normal  inhabitant  of  the 
body,  and  accordingly  the  body  establishes  a  natural  immunity 
against  it. 

It  has  been  found  in  many  instances  that,  in  conditions  in  which  colon 


40  SURGERY  OF  THE  MOUTH  AND  JAWS. 

bacilli  were  found,  the  symptoms  were  not  due  to  them,  but  to  other 
organisms  also  present,  and  vaccine  made  from  these  bacteria  produce 
the  desired  immunity. 

TUMORS  AND  CYSTS. 

The  original  meaning  of  the  word  tumor  was  swelling,  but  as  it 
became  known  that  many  swellings  were  due  to  an  inflammatory  re- 
action or  to  some  infection  or  injury,  the  word  tumor  was  restricted 
to  growths  that  were  not  known  to  be  due  purely  to  injury  or  to  a 
recognized  parasitic  infection.  As  knowledge  of  pathology  increased, 
certain  enlargements  that  were  formerly  called  tumors  have,  as  their 
specific  cause  was  discovered,  from  time  to  time  been  withdrawn  from 
this  classification  and  placed  among  the  infectious  diseases.  It  is 
probable  that  this  process  of  elimination  will  continue  indefinitely.  The 
unmistakably  inflammatory  processes,  such  as  pus  infections,  were 
early  differentiated  from  tumors,  but  certain  of  the  more  chronic  in- 
fections— among  which  are  tubercle,  actinomycosis,  and  syphilis — 
cause  swellings  that  were  often  confounded  wtih  tumors.  Even  now 
it  is  sometimes  difficult,  clinically,  to  distinguish  between  them. 

Tumors  that  contain  fluid  are  called  cysts.  A  cyst  always  possesses 
a  definite  wall  of  special  tissue  that  has  grown  to  accommodate  its 
contents — not  simply  stretched.  This  eliminates  from  the  class  of  cysts 
such  accidental  accumulations  as  pus  or  blood,  and  also  the  simple 
distention  of  the  normal  duct  with  fluid.  For  example,  an  abscess, 
hematoma,  or  a  recent  obstruction  of  Wharton's  duct  does  not  con- 
stitute a  cyst;  but  a  permanent  obstruction  of  a  sublingual  duct,  which 
is  one  form  of  ranula,  is  a  true  cyst.  Fluid  areas  in  a  solid  tumor  may 
sometimes  be  spoken  of  as  a  cystic  degeneration. 

Tumors  are  often  classified  according  to  the  tissue  that  predomi- 
nates. Thus  we  have  lipomata,  that  are  composed  mostly  of  fat; 
fibromata,  composed  of  fibrous  tissue;  osteomata,  composed  of  bone. 
An  important  clinical  distinction  is  that  between  the  malignant  and 
non-malignant  tumors. 

Benign  Tumors. — A  non-malignant  tumor  is  one  that  grows  within 
a  definite  limiting  capsule  and  does  not  invade  the  neighboring  struc- 
tures, though  it  may  grow  between  them,  pushing  them  before  it,  or 
cause  them  to  atrophy  by  pressure.  A  benign  tumor  never  spreads  to 
some  distant  part  of  the  body  by  something  transmitted  through  the 
blood  or  lymph  streams,  as  do  malignant  tumors. 

Malignant  Tumors. — Malignant  tumors  have  no  definite  limiting 
capsule.  As  they  grow,  they  tend  to  infiltrate  neighboring  tissues,  the 
essential  cells  of  the  tumor  growing  directly  into  the  neighboring 
tissues.     Furthermore,  malignant  tumors  disseminate  to  distant  parts 


INFLAMMATIONS,  INFECTIONS,  TUMORS,  CYSTS.  41 

of  the  body  through  the  blood  or  the  lymph  streams.  When  wandering 
cells  lodge  at  some  distant  site,  they  begin  to  grow,  and  there  is  a 
secondary  tumor  of  the  same  character  at  this  site.  This  process  of 
distant  infection  is  called  metastasis,  and  by  it  the  whole  body  may 
become  permeated  with  the  tumor.  Tumors  that  tend  to  infiltrate 
neighboring  tissues,  but  do  not  cause  metastasis,  are  spoken  of  as  being 
locally  malignant.  Myeloma  is  an  example  of  this.  At  present  ma- 
lignant tumors  are  divided  into  three  primary  classes — sarcomata, 
endotheliomata,  and  carcinomata,  or  cancer. 

Sarcoma. — Sarcoma  is  a  term  applied  to  all  malignant  tumors  that 
arise  from  connective  tissues — such  as  bone,  muscle,  or  fascia — in 
contradistinction  to  those  that  arise  from  endothelial  or  epithelial  cells. 
The  metastasis  of  a  sarcoma  is  usually  through  the  blood  stream  and 
rarely  through  the  lymphatics.  Sarcomata  are  often  classified  according 
to  the  structures  they  represent.  Thus  we  have  osteo-,  fibro-,  and 
chondro-sarcomata,  etc.,  when  bone,  fibrous  tissue,  and  cartilage  can 
be  respectively  recognized  in  the  growth.  When  the  cells  fail  to  develop 
sufficiently  to  recognize  the  tissue  from  which  they  form,  they  are 
classified  according  to  size  and  shape  of  the  component  cells,  as  round 
cell,  spindle  cell,  and  giant  cell  sarcomata. 

EndCThElioma. — Endotheliomata  arise  from  the  endothelial  cells 
of  the  blood  vessels  or  serous  cavities.  The  blood  vessels  and  lym- 
phatic tissues  arise  originally  from  the  same  germinal  layer  as  does  the 
connective  tissue :  the  mesoblast.  Endotheliomata  somewhat  closely 
resemble  sarcomata,  from  which  they  have  more  recently  been  differ- 
entiated. 

"  Carcinoma. — Carcinoma,  or  cancer,  is  a  growth  of  epithelium  that 
breaks  through  the  normal,  limiting,  basement  membranes  and  invades 
the  subepithelial  tissues.  This  is  the  chief  distinguishing  feature 
between  cancer  and  a  benign  papilloma  or  wart.  The  cells  of  the  latter 
grow  toward  the  surface,  and  never  break  through  the  limiting  base- 
ment membrane.  The  metastasis  of  cancer  takes  place  through  the 
lymphatics,  and  it  is  for  this  reason  that  the  regional  lymph  nodes 
always  become  infected  with  the  growth.  Carcinomata  are  classified 
mainly  by  the  kind  of  epithelium  from  which  they  grow,  those  arising 
from  the  surface  being  squamous  carcinomata,  and  those  from  glandu- 
lar epithelium  being  adenocarcinomata.  In  the  nose  and  accessory 
sinuses  the  normal  ciliated  epithelium  may  be  replaced  by  squamous 
epithelium  at  the  site  of  a  developing  carcinoma.  Carcinomata  are  also 
classified  as  medullary  and  scirrhous,  according  to  the  softness  or  hard- 
ness of  the  growth. 

The  exact  classification  of  some  tumors  is  still  a  matter  of  question. 


CHAPTER  III. 

PREPARATION  OF  THE  HANDS,  OPERATIVE  FIELD, 
INSTRUMENTS,  AND  DRESSINGS. 

The  object  of  these  preparations  is  to  reduce  to  a  minimum  the 
amount  of  septic  material  that  may  be  introduced  into  a  wound.  Sur- 
gery cannot  be  done  under  the  circumstances  that  test  tube  experiments 
in  the  bacteriologic  laboratory  might  lead  one  to  deem  essential,  but 
fortunately  for  the  practicability  of  our  art  and  for  the  preservation  of 
the  race,  there  is  a  natural  resistance  on  the  part  of  the  tissues  that 
will  usually  overcome  any  moderate  bacterial  invasion. 

We  are  often  somewhat  prone  to  forget  what  we  owe  to  tissue  re- 
sistance, crediting  good  results  to  some  particular  agent,  when,  as  a 
matter  of  fact,  we  frequently  do  more  harm  than  good  by  our  activities. 
In  observing  the  technic  in  vogue  in  any  large  clinic,  where  the  opera- 
tors have  the  best  opportunities  for  clinical  observations  and  laboratory 
diagnosis,  one  must  be  impressed  with  the  simple  methods  and  the 
tendency  to  discard  antiseptics.  Complicated  methods  are  apt  to  mis- 
carry, and  to  do  more  harm  than  good. 

PREPARATION  OF  THE  SURGEON'S  HANDS. 

All  that  is  demanded  for  dental  work  and  mouth  examination  is 
ordinary  personal  cleanliness,  but  the  hands  should  be  cleansed  in  the 
presence  of  the  patient  before  each  examination  or  operation.  When 
bone  or  soft  tissues  are  to  be  invaded,  then  what  is  regarded  as  surgical 
cleanliness  is  to  be  adopted.  This  differs  from  the  former  in  degree — 
not  kind.  It  is  absolutely  impossible  to  free  the  skin  from  all  bacteria, 
but  their  number  can  be  greatly  reduced. 

To  clean  the  hands  for  an  operation,  the  nails  should  be  trimmed 
and  cleaned,  and  dead  cuticle  and  "hang  nails"  should  be  removed  from 
the  edges  of  the  nails.  A  surgeon's  nails  should  be  kept  cleaned  with 
a  brush,  and  not  require  the  use  of  a  scraper  or  "nail  cleaner."  The 
hands  and  forearms  to  above  the  elbows  are  scrubbed  with  a  brush  or 
wash  cloth  in  hot  water  and  soap  for  five  minutes.  It  is  customary  to 
subsequently  immerse  them  for  a  few  minutes  in  some  antiseptic  solution. 
In  the  way  this  is  ordinarily  done,  it  makes  little  difference  what  is  used 
if  it  causes  no  irritation  of  the  skin.  Ninety-five  per  cent  alcohol  used 
for  five  minutes  will  destroy  most  of  the  surface  bacteria,  and  has  sev- 
eral advantages  over  the  aqueous  antiseptic  solutions.     It  is  usually 

42 


PREPARATION  OF  HANDS  AND  INSTRUMENTS.  43 

non-irritating,  and  is  a  much  more  powerful  germicide  than  are  any  of 
the  solutions  that  can  be  habitually  borne  by  the  hands.  It  is  very 
deliquescent,  and  quickly  penetrates  into  wet  crevices  and  pores. 
Various  strengths  have  been  advocated  as  being  most  efficient,  but  we 
use  95  per  cent. 

To  remove  all  danger  of  transferring  bacteria  by  the  hands,  the  latter 
must  be  covered  by  rubber  gloves,  and  the  arms  with  sterile  sleeves.  If 
gloves  are  worn,  they  should  be  free  from  minute  holes,  and  should  be 
changed  if  punctured.  The  perspiration  that  collects  within  a  glove  is 
usually  germ-laden.  One  of  the  most  important  points  in  the  care  of 
a  surgeon's  hands  is  to  avoid  irritation  of  the  skin  and  exposing  them 
to  infectious  material,  such  as  pus. 

PREPARATION  OF  THE  OPERATIVE  FIELD. 

Within  the  mouth  little  more  can  be  done  than  the  removal  of  gross 
sources  of  sepsis  and  repeated  washing  with  a  non-irritating  fluid. 
Weak  solutions  of  essential  oils,  iodin,  permanganate  of  potassium,  or 
certain  other  chemicals  help  to  reduce  the  number  of  bacteria  present, 
but  their  strength  should  not  be  sufficient  to  cause  irritation.  One  of 
the  most  efficient  antiseptic  washes  is  a  50  per  cent  solution  of  alcohol. 
In  the  preparation  of  the  skin  of  an  operative  field,  it  was  formerly 
the  custom^  to  wash  the  skin  several  times  with  soap  and  water  and 
alcohol  or  ether.  This  might  be  followed  with  various  other  anti- 
septics. Of  late  the  simple  method  of  painting  the  skin  with  a  solution 
of  iodin  in  alcohol  has  become  rather  popular.  The  rationale  of  the 
latter  method  is  not  supported  by  laboratory  experiments,  but  in  prac- 
tice it  has  been  found  eminently  satisfactory,  and  is  less  annoying  to 
the  patient  than  repeated  prolonged  scrubbings.  Our  custom  is  as  fol- 
lows :  If  hair  is  present,  it  is  removed  several  hours  before  with  soap 
and  water  and  a  sharp  razor,  or  immediately  before  the  operation  with 
benzin  and  a  razor.  Dirt  and  scales  of  skin  are  removed  with  benzin. 
When  the  iodin  preparation  is  used,  the  skin  should  be  dry  before  being 
painted.  Just  before  the  operation,  a  2^/2  per  cent  solution  of  iodin 
in  alcohol  is  applied  to  the  skin  three  times  at  ten-minute  intervals.  If 
the  skin  is  dirty  or  scaly,  it  is  first  cleansed.  If  it  is  not  convenient  to 
make  the  three  separate  applications  of  the  weaker  solution,  then  U.  S. 
P.  tincture  of  7  per  cent  iodin  in  alcohol  is  applied  once  freely,  and  as 
soon  as  dry,  is  removed  with  alcohol.  If  the  full  strength  tincture  is 
left  on  the  skin,  it  is  apt  to  blister.  We  are  still  uncertain  whether  the 
value  of  this  mode  of  preparation  is  by  virtue  of  the  iodin,  alcohol,  or 
both.  During  "clean"  operations,  all  skin  is  covered  with  sterile  towels 
as  soon  as  the  incision  is  made. 


44  SURGERY  OF  THE  MOUTH  AND  JAWS. 

STERILIZATION  OF  INSTRUMENTS. 

It  is  an  almost  universal  custom  to  sterilize  instruments  by  boiling 
them  from  ten  to  twenty  minutes  in  plain  water.  At  sea  level,  water 
boils  at  100°C.  or  212°  F.  This  will  kill  nearly  all  pathogenic  bacteria, 
but  will  not  always  kill  spores.  Certain  staphylococci  and  the  spores 
of  anthrax  and  tetanus  will  resist  boiling  water  for  long  periods,  but 
it  is  probably  very  seldom  that  these  are  present.  It  is  possible  that 
some  of  the  bacteria  that  we  now  consider  harmless  are  not  so,  and  that 
certain  of  the  little  understood  chronic  diseases  are  due  to  infections 
with  organisms  that  we  now  consider  non-pathogenic.  It  may  there- 
fore occur  that  the  practice  of  partial  sterilization  will  be  discarded, 
and  that  some  time  in  the  future  all  instruments,  dressings,  etc.,  will  be 
sterilized  by  steam  or  water  at  a  higher  temperature  than  212°  F. 
Boiling  for  twenty  minutes  is  injurious  to  the  edges  of  fine-cutting 
instruments,  and  these  should  always  be  sharp.  It  is  therefore  usually 
customary  to  resort  to  some  form  of  chemical  sterilization.  One  plan 
is  to  dip  them  in  95  per  cent  carbolic  acid  and  then  boil  them  for  a 
minute.  Another  good  plan  is,  after  thoroughly  cleansing  them,  to 
place  the  knives  for  fifteen  minutes  in  95  per  cent  alcohol.  For  chem.- 
ical  sterilization  to  be  successful,  the  knives  must  be  absolutely  clean 
and  free  from  finger  marks.  It  is  a  good  plan  for  dentists  to  sterilize 
their  burs,  forceps,  etc.,  in  the  presence  of  the  patients.  This  can  be 
conveniently  done  immediately  after  using  them,  and  it  removes  a  doubt 
that  is  often  present  in  the  patient's  mind. 

Brushes,  wooden-handled  instruments,  etc.,  may  be  sterilized  in 
formaldehyde  vapor,  and  cabinets  for  this  purpose  may  be  improvised 
or  bought  from  supply  houses.  This  sort  of  sterilization  requires  a 
number  of  hours,  and  is  more  often  a  matter  of  show  than  result. 

STERILIZATION  OF  RUBBER  GLOVES. 

These  are  boiled  with  the  instruments,  and  should  be  thoroughly 
wet  inside.  Dry  sterilization  of  gloves  is  not  practical,  as  dry  heat 
drives  off  the  sulphur,  and  a  glove  will  stand  only  three  sterilizations  in 
a  steam  chamber. 

STERILIZATION  OF  CLOTHS,  DRESSINGS,  ETC. 

These  may  be  boiled,  but  this  is  not  convenient.  They  may  be  par- 
tially sterilized  in  steam  under  normal  atmospheric  pressure  at  sea  level 
in  twenty  minutes.  It  is  usually  customary  in  hospitals  to  subject  them 
to  steam  under  fifteen  pounds  pressure  for  ten  to  fifteen  minutes.  This 
will  give  absolute  sterilization.  In  sterilizing  dressings,  cloths,  etc.,  it 
is  essential  that  the  steam  penetrates,  and  for  this  reason  they  must  not 


PREPARATION  OF  HANDS  AND  INSTRUMENTS.  45 

be  packed  tighriy.     Steam,  even  under  fifteen  pounds  pressure,  will  not 
easily  sterilize  tightly  packed  cloths. 

Dry  heat,  such  as  a  hot  oven,  will  kill  bacteria  in  from  fifteen  min- 
utes to  one  hour,  depending  on  the  temperature,  but  dry  heat  does  not 
penetrate  as  well  as  steam.  Outside  of  hospitals  it  is  usually  more 
practical  to  buy  dressings  already  prepared  by  reliable  manufacturers. 

STERILIZATION  OF  SUTURES. 

Silk,  horsehair,  silkworm  gut,  wire,  etc.,  may  be  boiled  or  put  in  a 
pressure  sterilizer.  Catgut  may  be  boiled  in  oil,  ether,  or  alcohol,  after 
all  of  the  water  has  been  removed  in  a  dry  oven.  It  is  customary  to 
buy  catgut  already  prepared,  but  it  can  be  done  by  anyone  who  will 
give  it  proper  care. 


CHAPTER  IV. 

HEMORRHAGE,   SHOCK,  AND   ALLIED   COMPLICATIONS. 

While  most  of  the  compHcations  that  may  follow  surgical  opera- 
tions are  preventable,  they  will  nevertheless  occasionally  arise.  When 
conditions  are  present  that  predispose  to  any  of  these  complications,  such 
conditions  may  usually  be  recognized  in  a  careful  preoperative  exam- 
ination, and  be  corrected  by  proper  treatment. 

HEMORRHAGE. 

Prevention  of  Hemorrhage. — In  surgical  operations  the  unnec- 
essary loss  of  blood  is  to  be  rigidly  avoided,  and  the  control  of  hemor- 
rhage should  always  be  considered  in  planning  the  technic.  Wherever 
possible,  vessels  should  be  isolated  and  temporarily  or  permanently 
ligated  before  being  cut,  and  every  cut  vessel  that  continues  to  give  a 
flow  sufficiently  large  to  be  recognized  as  an  individual  source  of  hem- 
orrhage should  be  controlled. 

The  proper  planning  of  incisions,  and  the  controlling  of  the  larger 
vessels  before  cutting  them,  constitute  our  most  potent  prophylactic 
measures.  For  operations  on  the  face  the  control  of  one  external 
carotid  is  not  always  sufficient,  on  account  of  the  number  and  size  of 
the  anastomoses,  especially  if  there  is  any  arterial  sclerosis.  We  have 
found  that  the  plan  of  temporarily  clamping  both  external  carotids,  or 
one  external  and  the  other  common  carotid,  serves  the  purpose  well. 
We  believe  that  the  common  carotid  should  never  be  tied  without  abso- 
lute necessity,  and  both  common  carotids  should  not  be  clamped  at  the 
same  time. 

The  position  of  the  patient  especially  influences  venous  bleeding, 
which  is  greatest  when  the  head  is  low,  by  sheer  weight  of  the  column 
of  blood  in  the  veins.  If,  to  avoid  aspiration  of  blood,  the  head  is  al- 
lowed to  hang  downward  during  an  operation,  this  objectionable  fea- 
ture may  be  somewhat  ameliorated  by  having  the  table  in  such  a  posi- 
tion that  the  trunk  and  limbs  slope  slightly  downward^the  reverse 
Trendelenburg  position. 

The  sequestration  of  blood,  after  the  manner  proposed  by  Dawbarn, 
holds  a  certain  amount  in  reserve,  and  we  have  resorted  to  it  when  free 
hemorrhage  is  anticipated.  It  is  accomplished  by  fastening  elastic 
bands  around  the  extremities,  close  to  the  trunk,  at  such  tension  that 
the  venous,  but  not  the  arterial,  flow   is   retarded.     This  causes  the 

46 


HEMORRHAGE  AND  SHOCK.  47 

veins  and  capiiraries  to  become  engorged.  Later,  when  the  bleeding 
is  controlled,  this  reserve  is  liberated. 

If,  for  any  reason,  it  is  suspected  that  the  clotting  power  of  the 
blood  is  below  normal,  the  clotting  time  should  be  ascertained,  and  if 
sluggish,  an  attempt  should  be  made  to  remedy  the  defect.  It  is  our 
practice  to  obtain  some  idea  of  the  clotting  time  in  all  cases  of  elective 
operations.  One  very  simple,  yet  practical,  way  of  doing  this  is  to 
obtain  a  drop  of  blood,  about  8  or  10  millimeters  in  diameter,  on  a 
clean  glass  slide.  In  obtaining  the  blood,  the  end  of  a  finger  or  the 
lobe  of  an  ear  is  stuck  with  a  cutting  needle.  The  blood  must  flow- 
without  squeezing  the  part,  as  squeezing  lessens  the  clotting  time. 
The  point  of  a  clean  needle  is  passed  through  a  new  place  on  the  edge 
of  the  drop  every  minute  until  a  distinct  string  of  fibrin  can  be  made 
to  adhere  to  the  needle,  which  occurs  just  a  little  before  the  true  clot 
is  formed.  This  method  is  sufificiently  accurate  for  practical  purposes. 
A  more  exact  way  is  to  draw  the  blood  up  into  a  freshly  made  capillary 
tube  1  or  ^  millimeters  on  its  inside  diameter.  A  short  section  of  the 
tube  is  broken  off  each  minute,  or  a  part  of  the  blood  is  blown  out  of 
the  tube  at  minute  intervals.  As  soon  as  the  clot  forms,  the  fibrin  is 
seen  stretching  between  the  separate  tube  ends,  or  it  can  no  longer  be 
expelled  by  blowing.  Still  more  exact  methods  are  employed  in 
physiological  laboratories.  A  deficiency  in  clotting  power  may  be 
natural  or  acquired.  The  formation  of  the  clot  depends  on  the  presence 
of  three  elements — thrombogen,  thrombokinase  (both  supplied  by  the 
blood  or  the  tissues  with  which  the  blood  comes  in  contact),  and  cal- 
cium ions  (also  normally  present  in  sufficient  quantity). 

Were  calcium  the  element  lacking,  it  could  be  easily  supplied.  It 
has  been  our  experience  and  that  of  Dr.  Sluder,  who  uses  calcium 
lactate  as  a  routine  practice  before  tonsil  and  adenoid  operations  in 
children,  that  calcium  lactate  will  lessen  the  clotting  time  in  almost  all 
cases.  Between  1  and  4  grams  are  given  daily  for  several  days  before 
the  operation  when  the  natural  clotting  time  is  over  four  minutes.  It 
is  not  unusual  for  the  clotting  time  to  be  reduced  by  this  from  as  high 
as  seven  down  to  three  minutes  or  less.  We  have  seen  even  more 
striking  reductions.  Judging  from  the  general  tone  of  the  literature, 
our  experience  with  calcium  lactate  has  been  more  fortunate  than  has 
been  that  of  some  others.  Lack  of  calcium  is  not  always  where  the 
fault  lies,  and  for  this  reason  various  other  therapeutic  agents  have  been 
proposed.  The  repeated  intravenous  injection  of  a  2  per  cent  solution 
of  gelatin,  in  normal  saline,  has  been  supposed  to  be  helpful,  but  our 
personal  experience  with  this  method  does  not  support  this. 

In  the  review  of  all  the  literature,  Wirth  states  that  gelatin,  calcium, 
and  ovarian  and  other  organotherapy  have  been  disappointing,  but  that 


48  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Weil's  method  of  subcutaneous  or  intravenous  injection  of  fresh  animal 
serum  is  far  better.  Thirty  cubic  centimeters  of  a  freshly  made  serum 
from  an  animal  should  be  injected  subcutaneously.  Where  conven- 
iences for  preparing  fresh  serum  are  not  at  hand,  an  antitoxic  serum 
has  been  used,  but  it  is  not  as  good  as  the  fresh  serum.  Good  results 
have  sometimes  been  obtained  from  the  local  application  of  a  foreign 
serum;  or  blood  to  the  wound. 

Morawitz  has  proposed  defibrinated  blood  transfusion  as  a  styptic 
and  reports  good  results.  But  in  these  cases  improvement  did  not 
shov^  until  after  forty-eight  hours.  Holt  recommends  this  highly. 
We  have  had  excellent  results  from  direct  blood  transfusion.  General 
hygiene,  tonic  medication,  and  feeding  should  not  be  overlooked. 

The  lack  of  clotting  may  be  due  to  an  increased  percentage  of  salts 
in  solution,  as  the  presence  of  bile  salts,  or  to  certain  diseases  or  pois- 
ons, as  sepsis,  scurvy,  hemophilia,  or  purpura.  When  possible,  the 
causes  of  these  conditions  should  be  treated;  or,  by  serum  injections  or 
by  direct  transfusion,  a  blood  that  will  clot  should  be  obtained  before 
an  operation  is  undertaken.  The  clotting  time  in  the  individual  may 
vary  from  time  to  time.  When  reduced  by  the  administration  of  cal- 
cium, we  have  noticed  that  it  begins  to  rise  again  within  a  few  days 
after  the  drug  is  withdrawn.  As  hemorrhage  continues,  the  clotting 
time  decreases.  We  have  learned  from  clinical  observations  that  in  the 
same  patients  the  clotting  time  may  change  from  time  to  time  without 
apparent  cause. 

Control  of  Hemorrhage. — Hemorrhage  is  designated  as  arterial, 
venous,  or  capillary,  according  to  its  source,  but  as  a  matter  of  fact  in 
almost  every  instance  it  is  a  combination  of  all  three,  with  one  pre- 
dominating. To  intelligently  treat  bleeding,  one  must  understand  and 
work  in  harmony  with  the  natural  hemostatics,  without  the  existence 
of  which  all  the  surgeon's  efforts  would  be  futile.  These  are  the  re- 
traction and  contraction  of  the  cut  vessel,  the  lowering  of  the  blood 
pressure  by  diminution  of  the  strength  of  the  heart's  action  and  of 
the  arterial  tone,  and  most  important  of  all,  the  clotting  of  the  blood. 
The  clotting  is  facilitated  by  the  retraction  and  contraction  of  the  ves- 
sels and  by  the  lowered  blood  pressure. 

Arterial  bleeding  is  usually  controlled  by  digital  pressure,  forceps 
pressure,  torsion  or  ligation  of  the  bleeding  ends,  or  by  ligation  of  the 
vessel  and  tissues  en  masse  by  means  of  deep  sutures.  Bleeding  from 
the  vessels  situated  in  bony  canals,  such  as  the  inferior  dental  or  pos- 
terior palatine,  may  be  controlled  by  inserting  a  peg,  or  pieces  of  mus- 
cle, or  connective  tissue,  into  the  canal,  or  by  occluding  it  by  pressing 
in  a  soft  piece  of  wax.  The  formula  of  Horsley,  carbolic  acid,  1  part ; 
olive  oil,  2  parts;  white  wax,  7  parts,  is  very  serviceable.     The  wax  is 


HEMORRHAGE  AND  SHOCK.  49 

sterilized  by  heat,  and  while  still  liquid  is  floated  out  on  cold  sterile 
water.  Pieces  of  the  congealed  wax  may  be  forced  into  the  bone 
spaces  and  canals.  When  the  bleeding  point  cannot  be  attacked 
directly,  the  outflow  can  be  lessened  and  clotting  favored  by  tying  the 
artery  any  place  proximal  to  the  bleeding  point.  Where  an  artery  has 
few  and  small  anastomoses,  such  as  the  lingual,  this  plan  is  very 
effectual. 

Ligatures,  whether  of  silk  or  catgut,  should  be  drawn  just  tight 
enough  to  close  the  lumen  of  the  vessel  and  to  prevent  slipping.  They 
should  not  cut  any  of  the  coats,  which  would  predispose  to  secondary 
hemorrhage.  If  there  is  not  a  sufficient  amount  of  the  vessel  exposed 
to  insure  the  ligature  against  slipping,  the  strand  should  be  engaged 
in  the  tissues  by  means  of  a  needle.  The  vessels  should  be  tied  with  a 
square  knot,  and  the  forceps  should  be  released  just  as  the  first  tie  of  the 
knot  is  drawn  tight.  Except  on  large  vessels,  as  a  cut  lingual,  only 
catgut  ties  should  be  used  in  closed  wounds  of  doubtful  asepsis.  Silk 
may  be  used  in  open  wounds  and  in  aseptic  closed  wounds. 

In  wounds  of  any  depth,  especially  if  the  vessels  cut  are  not  too 
large,  the  bleeding  may  be  controlled  by  a  temporary  packing  with 
gauze.  If  this  is  done  aseptically,  the  wound  may  on  the  second,  third, 
or  fourth  day  be  closed  by  secondary  sutures,  which  might  have  been 
put  in  at  the  time  the  packing  was  placed.  If  the  wound  is  not  suffi- 
ciently deep  to  maintain  the  packing,  it  may  be  fixed  in  place  with 
sutures,  the  pressure  of  a  bandage,  or,  in  some  parts  of  the  mouth,  by 
fastening  the  lower  to  the  upper  jaw  by  ligating  the  teeth,  or  less 
effectually  by  a  Barton  bandage. 

One  of  the  most  effectual  and  convenient  ways  of  controlling  the 
bleeding  in  most  wounds  in  the  face,  mouth,  and  scalp  is  by  the  use 
of  deep  approximation  sutures,  which  should  be  drawn  just  sufficiently 
tight  to  accurately  approximate  the  cut  surfaces.  Unless  there  is  a 
grave  fault  in  the  clotting  power,  this  will  be  sufficient.  Greater  ten- 
sion will  cause  necrosis  and  risk  of  sepsis  along  the  suture  tracts. 

Bleeding  veins  had  best  be  tied,  but  a  light  pressure  will  control  the 
flow.  When  there  is  any  question  of  the  collateral  circulation,  a  longi- 
tudinal wound  in  a  large  vein,  such  as  the  internal  jugular,  may  be 
stitched  with  a  fine  catgut  or  silk,  or  even  patched  by  slitting  a  tribu- 
tary or  neighboring  vein  and  sewing  it  in  to  the  defect. 

Torsion,  tying,  packing,  and  plugging  replace  or  supplement  the 
natural  contraction  of  the  vessels  and  clotting  of  the  blood,  while  the 
ligation  of  an  artery  at  a  distance  lessens  the  local  blood  pressure. 

In  average  individuals  the  bleeding  from  capillaries  and  small  ves- 
sels needs  no  treatment.  Continued  capillary  oozing  is  almost  always 
due  to  slow  clot  formation,  and  may  be  treated  by  lowering  the  blood 


50  SURGERY  OF  THE  MOUTH  AND  JAWS. 

pressure  and  increasing  the  clotting  time,  and  also  by  the  local  appli- 
cation of  styptics,  pressure,  and  means  that  stimulate  the  contraction 
of  the  local  vessels.  The  direct  application  of  the  extract  or  powder 
of  suprarenal  bodies,  preferably  in  the  form  of  the  alkaloid — as  the 
1 :1000  solution  of  adrenalin  chlorid,  for  example — causes  a  contrac- 
tion that  will  often  control  the  bleeding  from  small  vessels  until  the 
clot  has  had  time  to  form.  The  application  of  cold,  usually  in  the 
form  of  ice  or  cold  water — either  directly  to  the  bleeding  area  or,  where 
this  is  not  practical,  to  some  related  area — also  lessens  the  caliber  of 
the  vessels,  and  is  therefore  helpful.  Hot  water  will  cause  a  contrac- 
tion and  also  hastens  clotting. 

On  account  of  the  association  of  vasomotor  reflexes,  the  application 
of  cold  to  certain  regions  will  cause  a  contraction  in  other  anatom- 
ically remote  areas.  The  immersion  of  one  hand  in  cold  water  will  in 
this  way  lessen  the  temperature  of  the  other  hand.  The  application 
of  an  ice  bag  over  an  inflamed  appendix  will  lessen  the  hyperemia  of 
the  organ,  and,  what  is  more  applicable  to  our  subject,  the  application 
of  ice  to  the  back  of  the  neck  will  cause  a  contraction  of  all  of  the 
vessels  of  the  head,  including  those  of  the  nose  and  mouth.  Cold  is 
very  efficient  in  moderating  and  controlling  the  bleeding  from  subcu- 
taneous injuries,  thus  limiting  the  size  and  extent  of  ecchymosis  and 
hematoma. 

For  persistent  bleeding  following  the  extraction  of  one  or  more 
teeth,  the  sockets  should  be  packed  with  antiseptic  gauze  or  cotton. 
The  selvage  of  the  gauze  is  convenient  for  this  purpose.  If  this  does 
not  control  the  bleeding,  two  to  four  thicknesses  of  the  gauze  are  laid 
smoothly  over  the  surface  of  the  packing  and  the  adjacent  gums,  and 
the  whole  is  covered  with  soft  modeling  compound  or  quick-setting 
plaster  of  Paris.  The  modeling  compound  (a  hard  wax  that  softens  in 
hot  water  and  is  used  by  dentists  for  taking  impressions  in  the  mouth), 
or  impression  plaster,  should  embrace  the  gauze-covered  gum,  and  be 
of  sufficient  bulk  to  be  in  contact  with  the  opposing  gums  or  the  teeth 
when  the  jaws  are  in  contact.  Before  the  wax  or  plaster  is  quite 
hard,  the  jaws  are  closed  firmly  and  held  in  this  position.  The  en- 
veloping wax  or  plaster  now  holds  the  gauze  in  a  position  under  slight 
pressure.  If  there  are  any  occluding  teeth  in  the  upper  and  lower 
jaws,  the  fixation  is  best  done  by  wiring  the  lower  to  the  upper  jaw, 
with  or  without  bands  (page  100).  If  there  are  no  teeth  to  which  to 
wire,  then  a  chin  bandage  must  be  depended  upon,  or  resort  may  be 
had  to  a  modified  Kingsley  splint  (page  01)  to  hold  the  gauze  in  place. 
Measures  should  also  be  instituted  to  increase  the  clotting  of  the  blood. 

Delayed  clotting  may  be  locally  treated  by  applying  foreign  serum 
or  blood  (Prevention  of  Hemorrhage,  page  46),  or  certain  coagulents. 


HEMORRHAGE  AND  SHOCK.  51 

such  as  alcohol,  boiling  water,  chemical  styptics,  or  the  actual  cautery. 
But  any  application  that  produces  a  slough  or  favors  sepsis  may  be 
only  temporarily  effective ;  for,  as  the  slough  separates,  or  the  extra- 
vascular  clots  are  liquefied,  unless  there  is  an  intravascular  clot  in  the 
intact  part  of  the  vessels,  the  bleeding  will  start  again.  Boiling 
water,  instantaneously  applied,  alcohol,  or  a  saturated  solution  of  anti- 
pyrin,  or  an  antiseptic  gauze  pack,  are  probably  the  best  local  styptics. 
The  actual  cautery  is  useful  to  touch  a  bleeding  point,  but  it  is  hardly 
applicable  to  the  surface.  Gauze  packing  may  be  impregnated  with  a 
5  per  cent  solution  of  collargolum,  or  colloidal  silver  in  water.  We 
have  found  that  this  is  non-irritating  and  antiseptic. 

The  presence  of  a  large  extravascular  clot  may  favor  the  persistence 
of  bleeding.  One  is  sometimes  surprised,  on  cleaning  the  clots  out  of  a 
bleeding  wound,  to  find  that  the  flow  rapidly  diminishes  and  ceases. 

After  hemorrhage  has  persisted  for  a  certain  time,  the  blood  pres- 
sure continuously  falls.  The  general,  and  with  it  the  local,  blood  pres- 
sure is  lowered  by  laying  the  patient  in  the  recumbent  position,  in- 
suring quiet  with  sedatives,  and  not  resorting  to  stimulants.  This 
is  an  imitation  of  the  faint  that  often  accompanies  severe  hemorrhage. 
To  raise  up  or  stimulate  a  patient  who  has  fainted  from  the  loss  of 
blood  is  but  to  invite  an  increase  of  the  bleeding.  Certain  drugs,  such 
as  the  nitrates,  will  lower  the  blood  pressure,  but  their  employment  has 
seldom  been  advocated.  Morphin,  though  a  stimulant,  is  most  valuable 
in  quieting  both  the  mind  and  body.  The  use  of  vasoconstrictor  drugs 
as  styptic,  that  cause  a  general  contraction  of  the  blood  vessels,  is  on 
physiological  grounds  to  be  unqualifiedly  condemned.  Vasoconstrictors 
cause  an  elevation  of  blood  pressure,  which  will  outweigh  the  benefit 
derived  from  the  relatively  slight  contraction  of  the  blood  vessels  that 
occur  at  one  point.  The  value  of  ergot  in  uterine  hemorrhage  is  not 
due  to  its  general  action,  but  to  its  selective  action  on  the  uterine  muscle. 

In  bleeding  of  moderate  severity,  resort  may  be  had  to  an  expe- 
dient proposed  in  a  German  clinic.  This  consists  in  keeping  the  pa- 
tient in  the  erect  or  sitting  posture  until  he  faints  and  then  laying 
him  flat.  By  this  means  syncope  must  come  earlier,  and  with  less  loss 
of  blood  than  in  the  prone  position.  As  bleeding  continues,  the  clot- 
ting time  continually  decreases  until  one  half  the  total  quantity  of  the 
blood  is  lost.  This  is  possibly  the  reason  why,  in  many  instances, 
apparently  hopeless  bleeding  finally  ceases  before  causing  death. 

Postoperative  Hemorrhage. — Primary  hemorrhage  should  be 
controlled  at  the  time  of  the  operation  or  injury.  If  this  has  been 
properly  done,  postoperative  bleeding,  which  is  due  to  the  slipping  of 
ligatures  or  the  expulsion  of  intravascular  clots  on  restoration  of 
normal  blood  pressure,  will  seldom  occur.     If  it  is  due  to  the  slipping 


52  SURGERY  OF  THE  MOUTH  AND  JAWS. 

of  a  ligature  or  the  expulsion  of  a  clot  from  a  larger  vessel,  it  is  usually 
best  to  catch,  and  either  re-tie  it,  or  simply  leave  the  forceps  in  place. 
Often  the  bleeding  can  be  controlled  by  removing  clots,  readjusting 
the  packing,  maintaining  the  recumbent  position,  quieting  the  patient 
with  a  little  morphin,  and  the  avoidance  of  any  pernicious  surgical 
activity.  As  stated  before,  the  patient  may  be  made  to  sit  up  until  he 
faints  and  then  laid  flat. 

Secondary  Hemorrhage.- — ^This  usually  occurs  some  days  after 
the  operation  or  injury.  It  may  follow  suppuration  or  the  separation 
of  the  sloughs,  and  presents  a  special  difficulty,  inasmuch  as  the  vessels 
involved  may  be  very  friable  or  held  in  a  dense  inflammatory  mass.  It 
is  best  treated  by  cleaning  out  the  wound  with  antiseptics,  cutting  in- 
struments, or  a  cautery  at  a  dull  red  heat,  and  the  use  of  any  other 
previously  mentioned  means  that  circumstances  dictate.  If  a  pack  is 
applied,  it  must  retard,  not  favor,  sepsis.  The  actual  cautery  is  dan- 
gerous in  the  neighborhood  of  large  vessels.  An  artery  can  be  ligated 
at  a  distance  to  control  bleeding  from  its  trunk  or  any  of  its  branches. 

The  efficiency  of  this  latter  procedure  varies  inversely  with  the  size 
and  number  of  the  anastomoses  distal  to  the  ligature,  because  the  col- 
lateral circulation  will  be  proportionally  active.  Ligation  of  the  lingual 
artery  will  effectually  control  bleeding  from  one  half  of  the  tongue, 
ligation  of  one  external  carotid  has  little  effect,  and  ligation  of  the  in- 
dividual branches  will  vary  in  efficiency  according  to  the  size  and 
number  of  their  communications.  The  ligation  of  the  internal  max- 
illary artery  is  too  difficult  to  be  practicable,  but  after  tying  the  ex- 
ternal carotid  above  the  occipital  artery,  the  temporal  can  be  tied 
above  the  origin  of  the  internal  maxillary,  which  will  leave  only  the 
transverse  facial,  the  posterior  auricular,  and  some  parotid  branches 
uncontrolled. 

A  patient  suffering  from  loss  of  blood  first  feels  faint,  and  possibly 
nauseated ;  if  the  erect  position  is  maintained,  he  may  fall.  With  mod- 
erately slow  progressive  hemorrhage  there  is  thirst  and  restlessness ; 
there  is  an  increasingly  rapid  and  weak  pulse,  with  a  continuous  fall  of 
blood  pressure;  the  skin  is  often  moist  and  clammy,  and  both  the  skin 
and  mucous  membrane  become  pale.  Eventually  there  is  air  hunger. 
The  condition  closely  resembles  the  restless  form  of  shock,  from  which 
it  is  often  difficult  to  distinguish  when  the  bleeding  does  not  show  on 
the  surface. 

Treatment  of  the  Effects  of  Hemorrhage. — With  rare  excep- 
tions, according  to  our  experience  and  opinion,  neither  stimulants  nor 
transfusion,  nor  any  other  method  of  raising  blood  pressure,  should  be 
employed  before  the  bleeding  is  at  least  temporarily  controlled.  If  the 
condition  of  the  patient  seems  critical,  quiet  should  be  insured,  if  nee- 


HEMORRHAGE  AND  SHOCK.  53 

essary,  with  a 'little  morphin  given  hypodermatically.  The  head  should 
be  on  or  below  the  level  of  the  body ;  the  limbs  may  be  elevated,  or  even 
bandaged,  to  keep  as  much  of  the  blood  as  possible  circulating  between 
the  heart,  the  lungs,  and  the  vital  centers ;  the  body  should  be  kept 
warm  by  blankets  and  artificial  heat.  Hot-water  bottles  placed  around 
an  unconscious  or  semiconscious  person  should  be  at  a  temperature 
of  115°  F.,  and  no  higher,  for  otherwise  the  patient  may  be  seriously 
burned. 

Once  the  loss  of  blood  is  controlled  after  a  severe  hemorrhage,  the 
vessels  should  be  filled  with  normal  saline  solution  at  a  temperature 
of  104°  F.  to  110°  F.  Fatal  hemorrhages  can  occur  through  loss  of 
fluid  when  there  are  still  enough  blood  cells  and  plasma  in  the  vessels 
and  tissues  to  comfortably  carry  on  function,  if  they  could  but  circulate. 
A  level  teaspoonful  of  salt  to  a  pint  of  water,  boiled  and  cooled  to  110° 
F.,  by  setting  the  vessel  in  a  pan  of  cool  water,  is  a  practical  way  of 
preparing  the  saline  solution.  It  should  be  introduced  either  directly 
into  a  vein,  under  the  skin,  or  into  the  rectum  at  a  temperature  of  100° 
F.  For  want  of  a  special  reservoir,  a  sterilized  fountain  douche  bag  is 
usually  accessible  and  is  very  effective.  It  is  difficult  to  accurately 
gauge  the  amount  of  fluid  that  is  slowly  running  from  a  rubber  douche 
bag,  but  if  the  bag  is  hung  on  the  ordinary  spring  balance  scale  that  is 
usually  found  in  every  house,  the  flow  can  be  gauged  with  some 
accuracy. 

SALINE  TRANSFUSION. 

Intravenous  Transfusion. — To  introduce  saline  directly  into  a 
vein,  the  cephalic,  median  cephalic,  or  median  basilic  are  the  veins 
usually  selected,  but  any  vein  of  sufficient  size  in  either  extremity  will 
answer.  Sometimes  the  long  saphenous  vein  in  front  of  the  internal 
malleus  is  more  accessible  than  are  those  of  the  upper  extremity.  The 
vein  may  be  tied  after  being  exposed  under  a  local  anesthetic,  the  ends 
of  the  ligature  remaining  long.  A  V-shaped  or  longitudinal  slit  is 
made  in  the  vein,  just  proximal  to  the  ligature,  and  the  point  of  a  glass 
eye-dropper  attached  to  the  douche  tube  is  slipped  into  the  vein.  A 
simpler  method  is  to  attach  a  fair-sized  hypodermic  needle  to  the  douche 
tube  and  insert  the  point  directly  in  the  vein  without  incising  the  skin. 
This  is  sometimes  very  difficult  to  do. 

It  is  needless  to  state  that  these  operations  should  be  done  asep- 
tically.  If  necessary,  a  vein  can  be  made  prominent  by  throwing  a 
bandage  around  the  upper  part  of  the  limb.  The  compression  bandage 
must  be  removed  before  allowing  the  saline  to  flow.  Fluid  should  not 
be  put  directly  into  the  vein  at  a  greater  rapidity  than  500  cubic  centi- 
meters in  ten  minutes,  and  the  flow  should  be  withheld  on  any  signs 


54  SURGERY  OF  THE  MOUTH  AND  JAWS. 

of  cardiac  embarrassment.  In  either  method,  the  second  sound  is  a 
good  index  to  the  heart's  condition.  The  air  and  cold  water  should  be 
expressed  from  the  tube  and  needle  just  before  inserting  by  holding 
the  needle  with  a  little  less  than  one  half  of  the  tubing  pointing  toward 
the  ceiling,  and  allowing  the  water  to  flow  until  it  comes  warm  from 
the  needle  unmixed  with  air.  Air  that  remains  in  the  tube  after  this 
will  not  be  carried  into  the  vein. 

Hypodermoclysis. — Saline  may  be  put  into  the  subcutaneous 
tissue  of  the  chest,  abdomen,  or  thighs  by  means  of  a  hollow  needle  and 
gravity.  This  method  is  more  painful  than  intravenous  transfusion, 
but  it  is  safer  and  usually  sufficiently  rapid.  Absorption  from  the  sub- 
cutaneous tissues  is  hastened  by  massage  and  kneading  of  the  indu- 
ration. 

Proctoclysis. — If  the  rectum  is  loaded  with  feces,  this  may  have 
to  be  removed  with  an  enema.  If  a  large  quantity  of  water  is  thrown 
into  the  rectum,  it  may  start  peristalsis  and  be  expelled.  If  the 
saline  solution  is  allowed  to  trickle  in,  its  absorption  is  more  certain. 
Ordinarily  it  should  not  be  allowed  to  flow  much  more  rapidly  than  it 
can  be  absorbed — one  or  two  drops  a  second.  This  latter  method 
was  first  proposed  by  J.  B.  Murphy.  Of  the  various  methods  of  in- 
troducing saline  into  the  circulation,  proctoclysis  is  the  freest  from 
danger,  and  the  one  most  commonly  employed. 

Water  flowing  slowly  into  the  rectum,  or  into  the  subcutaneous 
connective  tissue,  cools  rapidly  in  the  tube.  There  are  special  devices 
for  maintaining  the  proper  temperature,  a  very  efficient  one  having  been 
devised  by  O.  Elbrecht,  but  these  are  not  always  at  hand.  For  intrave- 
nous and  subcutaneous  transfusions,  if  it  is  found  necessary,  several 
coils  of  the  douche  tube  may  rest  in  a  basin  of  water,  or  be  wound 
around  a  hot-water  bottle  maintained  at  the  proper  temperature,  and 
held  very  close  to  the  patient.  For  slow  rectal  injections,  the  douche 
bag  is  held  very  little  above  the  level  of  the  bed,  and  all  of  the  tube  can 
be  under  the  bed  clothes  and  thus  kept  warm. 

If,  after  transfusion,  or  any  other  method  of  introducing  fluid  into 
the  circulation,  there  is  profuse  sweating,  it  should  be  controlled  with 
moderate  doses  of  atropin.  Even  where  this  is  due  to  shock,  the 
atropin  often  seems  helpful.  It  is  a  serious  question  to  our  mind  as 
to  whether  other  internal  stimulants  than  filling  the  vessels  and  the  use 
of  a  little  morphin  are  ever  indicated  in  the  treatment  of  hemorrhage. 

When  a  transfusion  is  done  with  saline,  the  blood  is  diluted,  which 
may  increase  the  clotting  time.  If  it  has  not  already  been  controlled, 
it  will  be  more  difficult  to  accomplish  this  after  than  before  the  saline 
transfusion,  on  account  of  both  increased  blood  pressure  and  decreased 
clotting  power.     If  repeated  hemorrhage  and  saline  transfusions  alter- 


HEMORRHAGE  AND  SHOCK.  55 

nate  several  times,  a  blood  of  very  poor  clotting  power  will  result. 
When  not  satisfied  that  the  source  of  the  bleeding  is  permanently  con- 
trolled, the  transfusion  should  be  with  blood. 

BLOOD  TRANSFUSION. 

Direct  blood  transfusion  is  done  by  connecting  a  blood  vessel  of  a 
donor,  who  is  free  from  transmissible  taint,  to  a  vein  of  the  patient  in 
such  a  way  that  the  blood  passes  from  the  donor  to  the  patient.  One 
method  of  doing  this  is  to  unite  the  radial  artery  of  the  donor  to  the 
cephalic  vein  of  the  recipient  in  such  a  way  that  the  blood  in  its  passage 
comes  in  contact  only  with  the  endothelial  lining  of  the  vessels.  The  ra- 
dial artery  and  cephalic  vein  are  selected  simply  for  convenience.  This 
is  usually  done  by  means  of  a  cannula,  first  devised  by  Payr,  and  of 
which  various  modifications  have  been  made.  The  operation  is  done 
under  a  local  anesthetic.  The  clinical  symptoms  evinced  by  the  donor 
and  donee  should  determine  the  length  of  the  operation.  A  strong, 
full-blooded  donor  in  the  recumbent  position  will  probably  lose  500  to 
800  cubic  centimeters  of  blood  before  showing  marked  symptoms.  A 
dog  may  bleed  to  the  last  drop  and  be  perfectly  restored  by  this  method. 
This  operation,  while  apparently  simple,  is  not  apt  to  be  conducted 
smoothly  by  one  who  has  never  performed  it.  Even  in  the  hands  of 
one  more  or  less  expert,  it  is  not  always  successful.  The  two  people  to 
be  operated  upon  should  be  placed  in  the  proper  juxtaposition,  and 
sufficient  of  each  vessel  should  be  freed.  The  arteriovenous  operation 
has  two  serious  difficulties  inherent  to  it — one,  the  lesser,  is  that  an 
artery  has  to  be  freed,  and  the  other  is  that  the  cannulae  are  very  min- 
ute, somewhat  difficult  to  handle,  and  give  very  little  room  for  the 
blood  stream.  It  is  for  these  reasons  that  we  look  on  the  method  de- 
vised by  Dorrance  and  Ginsburg  as  superior,  which  consists  in  uniting 
the  distal  end  of  a  vein  of  the  donor  to  the  proximal  end  of  the  recip- 
ient's vein. 

Lewisohn's  Method  of  Sodium  Citrate  Blood  Transfusion. — 
Lewisohn's  experiments^  have  shown  that  0.2  per  cent  of  sodium 
citrate  in  blood  is  sufficient  to  prevent  coagulation  outside  the  body 
for  2  or  3  days.  Five  grams  of  sodium  citrate  represents  the  largest 
amount  that  can  be  safely  introduced  into  an  adult.  1000  c.c.  of 
blood  containing  0.2  per  cent  citrate  only  represents  2  grams  of 
sodium  citrate.     The  technique  employed  by  Lewisohn  is  most  simple. 

1.  Obtaining  the  Blood  from  the  Donor. — A  tourniquet  is  applied 
to  the  donor's  arm  and  one  of  the  veins  at  the  bend  of  the  elbow 
punctured.  A  large  cannula  is  used  so  the  blood  will  flow  rapidly. 
The  blood  is  allowed  to  fall  into  a  graduated  glass  jar  which  con- 

iJournal   of  the  A.   M.   A..   March   17.    1917,   826. 


56  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tains  2  per  cent  sodium  citrate  solution  in  quantity  necessary  to 
make  a  0.2  per  cent  solution  in  the  amount  of  blood  to  be  given. 
For  example,  if  we  want  to  give  450  c.c.  of  blood,  we  add  this  to 
50  c.c.  of  the  2  per  cent  citrate  solution.  The  blood  is  well  stirred 
as  it  falls  into  the  jar.  Care  must  be  taken  never  to  have  less  than 
0.2  per  cent  of  sodium  citrate,  or  the  blood  will  coagulate.  A 
slight  surplus  of  citrate  solution  will  prevent  this  and  can  be  added 
with  perfect  safety. 

2.  Infusion  of  Blood  into  the  Recipient. — The  citrated  blood  is 
either  administered  through  a  funnel  or  transferred  to  a  glass  in- 
fusion jar.  The  patient's  ivein  usually  has  to  be  exposed  through  a 
small  incision.  The  cannula  is  inserted  and  attached  to  a  funnel  or 
infusion  jar  which  contains  20  or  30  c.c.  of  physiologic  saline 
solution.  The  citrated  blood  is  then  poured  into  this  receptacle  and 
allowed  to  flow  into  the  vein  by  gravitation. 

Before  resorting  to  transfusion  in  any  case,  whenever  possible 
a  Wassermann  test  must  be  made  on  the  donor,  and  the  blood  of 
the  donor  and  recipient  must  be  tested  for  agglutination  and 
hemolysis.  Neglect  of  these  precautions  may  bring  disastrous  re- 
sults. 

The  simplicity  of  Lewisohn's  technique  renders  it  available  to  all, 
and  makes  it  superior  to  all  other  methods  of  transfusion,  either 
direct  or  indirect. 

SHOCK. 

It  is  easier  to  prevent  than  to  efifectually  treat  shock.  Fear,  loss 
of  blood,  rough  handling  of  richly  innervated  tissues  and  nerve  trunks, 
chilling  of  the  surface,  and  prolonged  operations  are  all  conducive  to 
shock.  It  is  difficult  to  estimate  the  resistance  of  the  individual,  and 
therefore  the  energies  should  always  be  conserved.  Old  people,  with 
high  blood  pressure,  stand  the  loss  of  blood  poorly,  and  the  supervening 
shock  comes  suddenly.  Shock  is  accompanied  by  a  fall  of  blood  pres- 
sure ;  in  fact,  the  latter  may  be  taken  as  an  indication  of  the  degree  of 
the  shock.  Except  in  cases  of  advanced  arteriosclerosis,  in  cases  of 
increased  intracranial  pressure,  and  in  cases  where  the  shock  is  pro- 
duced by  a  sudden  injury — as  cutting  large  nerve  trunks  or  chiseling 
on  the  skull — the  stage  of  severe  shock  is  usually  preceded  by  a  some- 
what gradual  loss  of  pressure.  Therefore,  in  all  operations  in  which 
shock  might  develop,  it  is  a  wise  precaution  to  keep  track  of  the  blood 
pressure  by  palpation  of  an  artery,  or,  more  accurately,  by  frequent 
readings  from  a  sphygmomanometer. 

One  of  the  most  concise  descriptions  of  shock  has  been  given  by 
Moullin : 


HEMORRHAGE  AND  SHOCK.  57 

Two  varielies  of  shock  are  described — the  one  characterized  by  ex- 
treme depression ;  the  other,  which  is  much  more  rare,  by  great  excite- 
ment. Upon  what  the  difference  depends,  why  one  form  should  occur 
and  not  the  other,  is  not  known. 

In  the  ordinary  form  the  patient  lies  perfectly  quiet,  with  the  eye- 
lids half  closed  and  the  limbs  in  the  position  that  chance  may  have 
placed  them ;  conscious,  but  paying  no  attention  to  anything  around ; 
able  to  speak  feebly  and  slowly,  but  entirely  incapable  of  any  mental 
effort.  The  face  has  lost  all  expression ;  the  skin  is  cold,  pale,  and 
clammy,  that  on  the  forehead  often  being  covered  with  perspiration ; 
the  pulse  is  frequent,  generally  more  or  less  irregular,  the  artery  seem- 
ing to  collapse  and  empty  itself  with  each  beat ;  the  respiration  is  shallow, 
and  the  temperature  far  below  normal — sometimes  as  much  as  three 
or  four  degrees.  The  sphincter  ani  is  usually  relaxed;  urine,  if  the 
bladder  is  full  at  the  time  of  the  accident,  is  retained,  but  afterward  for 
many  hours  the  secretion  stops  almost  altogether. 

In  the  worst  cases,  such  as  are  almost  certain  to  prove  fatal,  there 
is  complete  absence  of  the  sense  of  pain.  The  writer  has  many  times 
seen  patients  dreamily  looking  on,  without  a  sign  of  intelligence,  while 
broken  fragments  of  bone  were  being  removed  and  search  made  for 
bleeding  arteries  in  limbs  that  had  been  crushed  in  a  railway  accident. 

Vomiting  is  of  frequent  occurrence;  in  head  injuries  it  not  uncom- 
monly marks  the  onset  of  reaction.  In  a  few  moments  the  face  be- 
comes flushed,  and  the  pulse  regains  its  vigor  and  fullness.  In  other 
cases  it  may  either  occur  at  the  commencement,  when  it  is  compara- 
tively of  little  significance,  or  later,  after  a  few  hours,  and  then  it  not 
uncommonly  marks  the  beginning  of  the  end. 

Shock  may  be  almost  instantaneously  fatal.  The  author  has  known 
death  to  occur  within  five  minutes  from  puncturing  a  small  hydatid 
cyst  in  the  liver,  or  it  may  begin  more  gradually  and  slowly  become 
worse  and  worse  until  death  ends  the  scene. 

The  other  variety,  that  which  is  characterized  by  furious  excitement, 
is  more  uncommon.  Its  onset  is  nearly  always  gradual ;  at  the  first 
there  is  some  ground  for  hope,  and  the  general  condition  appears  not 
altogether  unsatisfactory,  although  the  pulse  is  very  rapid  and  devoid 
of  power ;  very  soon,  however,  the  patient  becomes  restless  and  begins 
to  talk  volubly  and  incoherently ;  delirium  sets  in ;  the  limbs  are  thrown 
wildly,  utterly  regardless  of  pain,  and  in  a  short  time  this  is  followed 
by  a  condition  resembling  furious  mania.  The  result  is  invariably 
fatal  from  collapse. 

Diagnosis.— Syncope  due  to  failure  of  the  blood  supply  to  the 
brain  rarely  causes  any  difficulty;  with  hemorrhage,  especially  when  it 
is  internal,  it  is  different.     In  many  cases  of  injury  to  the  abdominal 


58  SURGERY  OF  THE  MOUTH  AND  JAWS. 

viscera  it  is  practically  impossible  to  make  a  diagnosis — the  two  are 
so  often  associated.  Given  a  case  of  severe  contusion  followed  by  col- 
lapse, it  may  be  due  to  shock  alone  or  to  shock  complicated  by  hemor- 
rhage from  rupture  of  the  viscera  or  tearing  of  a  mesenteric  artery  or 
vein,  and  there  is  no  certain  method  of  separating  one  condition  from 
the  other.  Failure  of  sight  due  to  anemia  of  the  retina,  constant 
yawning  or  deep  sighing  inspirations,  and  throwing  the  arms  over  the 
head  are  very  suggestive  of  hemorrhage,  but  nothing  more;  and  a 
great  deal  of  blood  may  collect  in  the  abdominal  cavity  without  causing 
any  marked  degree  of  dullness. 

Treatment. — The  expeditious  operator,  who  uses  ordinary  judg- 
ment, will  seldom  have  to  deal  with  severe  shock  of  his  own  produc- 
tion. Operations  should  be  carefully  planned  and  nicely  executed. 
They  should  never  be  begun  without  a  definite  plan  of  technique  and  of 
cooperation  on  the  part  of  the  assistants  and  anesthetist.  Many  opera- 
tions can  advantageously  be  done  in  two  stages.  The  patient  should 
have  his  fears  allayed  before  the  operation.  During  the  operation  the 
patient  should  be  kept  dry  and  enveloped  in  woolen  blankets  or  rubber 
dam.  Excessive  loss  of  blood  should  be  immediately  followed  by 
rectal,  subcutaneous,  or  intravenous  infusions  of  salt  solution.  Where 
practical,  large  nerve  trunks  should  be  blocked  by  the  injection  of  a 
1  per  cent  solution  of  cocain  or  novocain  directly  into  the  sheath  before 
they  are  cut.     The  same  holds  true  for  the  superior  laryngeal  nerve. 

Until  we  learn  the  true  pathology  of  shock,  all  treatment  must  re- 
main empirical.  Varied  as  are  the  views  as  to  the  precise  nature  of 
this  condition,  there  is  a  unanimity  of  opinion  that  the  prime  essentials 
in  the  treatment  are  bodily  warmth  and  mental  and  physical  rest. 
Warm  blankets  and  hot-water  bags,  or  bottles,  will  insure  the  former ; 
while  for  the  latter  we  are  much  dependent  on  the  behavior  of  those 
around  the  patient.  Morphin  in  small  doses  hypodermatically  is  often 
very  useful.  The  value  of  stimulants  in  shock  is  a  mooted  question, 
but  it  is  probable  they  are  given,  as  a  rule,  rather  from  the  desire  to 
be  doing  something  than  from  any  warranted  conviction  as  to  their 
utility.  If  a  stimulant  is  to  be  administered,  it  is  possible  that  an  ordi- 
nary hypodermic  syringeful  of  neutral  camphorated  oil  injected  every 
half  hour  will  be  found  to  be  as  useful  as  any  and  open  to  fewer  objec- 
tions. If  intravenous  or  subcutaneous  infusion  of  saline  is  resorted 
to,  it  should  be  supported  and  sustained  by  adrenalin  and  atropin. 

Because  of  the  supposed  loss  of  vasomotor  control  and  consequent 
sequestration  of  blood  in  the  abdominal  veins,  bandaging  of  the  limbs 
in  severe  shock  has  been  a  common  practice,  and  Crile  elaborated  a 
pneumatic  suit  for  maintaining  the  blood  pressure.  Even  if  effective, 
the  latter  is  at  Ibe  disposal  of  but  few,  Init  it  can  l)e  imitated  by  bandag- 


HEMORRHAGE  AND  SHOCK. 


59 


ing  the  inner  tube  of  a  bicycle  tire  to  the  extremities  and  trunk,  and 
then  inflating  the  tubes.  After  all,  however,  aside  from  rest,  the 
restoration  of  the  normal  bulk  of  fluid  in  the  vessels,  the  maintenance 
of  bodily  warmth  and  of  mental  and  physical  rest,  and  the  elimination 
of  pain,  shock  is  best  treated  in  a  negative  way. 

AIR  EMBOLISM. 

If  air  enters  a  vein  in  sufficient  quantity  to  reach  the  right  auricle, 
grave  depression  or  death  may  follow.  If  any  conclusion  can  be 
drawn  from  animal  experimentation,  it  must  be  that  the  danger  result- 
ing from  air  in  the  right  heart  is  considerably  exaggerated  in  most 
textbooks,  although  there  are  a  number  of  apparently  authentic  cases 


Fig.  9.  Experiment  IIB.  Tracing  made  from  ventricle  of  a  cat  while  repeated 
injections  of  air  were  made  into  the  jugular  vein.  The  interruptions  in  the  contrac- 
tions are  plainly  shown. 

of  death  from  this  cause.  In  1885,  Senn  collected  about  twenty  such 
instances. 

In  a  carefully  conducted  series  of  experiments  on  cats  and  dogs, 
which  were  made  for  the  purpose  of  obtaining  accurate  data  for  this 
subject,  during  which  blood  pressure  tracings  were  taken  while  and 
after  measured  quantities  of  air  were  let  or  forced  into  the  jugular 
vein,  it  was  observed  that  there  was  both  a  mechanical  and  a  vital  dis- 
turbance on  the  entrance  of  the  air  into  the  right  heart.  The  air  de- 
stroyed the  action  of  the  valves,  and  at  the  same  time  the  heart's  effort 
was  decreased  (Fig.  9).  As  a  result  the  blood  pressure  would  fall 
dangerously  low— sometimes  almost  to  zero. 

The  amount  of  air  required  to  kill  different  animals  of  the  same 
species  varied  enormously,  which  possibly  explains  the  lack  of  uniform- 
ity in  the  published  clinical  reports  on  the  subject  (Figs.  10  and  11). 
Based  on  the  observations  made  during  these  experiments,  the  treat- 
ment we  propose  for  air  embolism  accompanied  by  serious  symptoms 
is  the  introduction  of  adrenalin  chlorid  in  a  fairly  concentrated  solution, 


60 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


1:10,000  to  1:1000,  directly  into  the  right  ventricle,  and  this  should 
be  accompanied  by  a  small  amount  of  normal  saline  solution.  In  our 
experiments  on  dogs  we  used  40  cubic  centimeters  or  more  of  saline 
solution ;  but  in  most  cases  a  large  quantity  of  air  had  been  put  in  under 
pressure,  and  it  required  a  pressure  of  60  centimeters  of  water  to  force 
the  fluid  into  the  vein   (Fig.  12). 

For  clinical  application,  a  fine  hypodermic  needle  might  be  pushed 
through  the  chest  wall  directly  into  the  right  heart.  This  could  be 
done  by  inserting  the  needle  through  the  chest  wall  and  lung  at  the 
anterior  extremity  of  the  third  or  fourth  right  intercostal  spaces.  We 
observed  no  evil  effects  in  dogs  from  perforating  the  heart  wall  with  a 
fine  needle,  but  to  attempt  to  do  it  through  the  chest  wall  would  be  a 
very  uncertain  procedure. 


•'if:iis&6t23ssx-sA^:&'t 


m,^  cu,  ^oj. 


lj.n         (fi  crM-«4«'w^, , 


-  \i,<u.  ^iojuc-r^-  •^^' 


Fig.   10.      Experiments    5    and    7. 
Death   from  injection  of  air  into  the  jugular  veins  of  two  cats. 


Time. 
10:03 
10:05 
10:07 
10:09 
10:12 


Normal    pressure    

4.5  CO.  air  in  jugular- 


Experiment  5,  March  16,  1910. 
Cat,  weight  3500  Grams   (male). 

Blood  pressure  Hg. 

164  mm. 

80  mm. 

150  mm. 

4.5   c.c.    air   in   jugular 30  mm. 

40  c.c.   salt  solution 20  mm. 

Containing   1    c.c.    adrenalin,  this  was   repeated   in   1    minute — no   sign   of   recovery. 
11 :20  :     Animal  dead. 

Postmortem :     A  clot  in  right  heart.     Air   in   right  heart,  lungs,   and  inferior  vena 
cava  back  to  liver  ;  no  air  in  left  heart. 

Experiment  7,  March  16,  1910. 
Cat,  weight  2500  Grams. 
Blood  pressure  134  mm.     Was  injected  with  9  c.c.  of  air.     Pressure  fell  at  once  to 
zero,  and  treatment  with  adrenalin  and  salt  was  ineffective. 

Autopsy :      Showed    air    in    all    abdominal     veins,    air    in    right    heart,    no    air    in    left 
heart,  not  dilated. 


HEMORRHAGE  AND  SHOCK. 


61 


Pig.  11.  From  Experiments  4,  1,  3,  and  14.  Experiment  4  :  Dog  revived  of  itself. 
Experiment  1  :  Cat  revived  with  .9  saline.  Experiment  3  :  Cat,  which  failed  to  revive 
with  .9  saline,  was  revived  with  .9  saline  and  adrenalin.  Experiment  14,  drum  3  :  Dog 
revived  with  adrenalin   in  a  concentrated  solution. 


Fig.  12.  Experiment  14,  drum  3.  Shows  fall  in  pressure  after  injecting  40  c.c.  of 
air  in  the  jugular  vein  of  a  dog  and  the  excessive  rise  in  blood  pressure  on  injecting 
1  c.c.  of  a  1  :1000  solution  of  adrenalin  chlorid.  This  excessive  pressure  was  controlled 
by  taking  75  c.c  of  blood  from  the  femoral  artery.  Tte  resulting  fall  in  blood  pressure 
is  shown  on  the  tracing. 

Air  embolism  usually  results  from  operations  in  the  neck  in  which 
large  veins  are  exposed.     We  believe  a  practical  application  of  this 


62  SURGERY  OF  THE  MOUTH  AND  JAWS. 

treatment  would  be  to  insert  a  douche  point  or  transfusion  needle,  at- 
tached to  some  sort  of  transfusion  apparatus,  or  douche  can  containing 
normal  saline.  The  adrenalin  chlorid  can  be  introduced  into  the  tube 
of  the  douche  apparatus  close  to  the  vein  by  piercing  it  with  a  hypo- 
dermic needle.  The  water  can  be  put  in  with  safety  at  a  pressure  of 
25  to  30  centimeters  of  water  pressure. 

In  regard  to  the  quantity  of  a  1 :1000  adrenalin  solution  to  be  used, 
we  suggest  that  2  cubic  centimeters  be  tried  in  a  severe  depression  and 
repeated. 

In  dogs  34  cubic  centimeter  was  sometimes  efifective,  and  the  ex- 
treme activity  resulting  from  a  large  dose  was  of  but  short  duration. 
Any  dangerous  symptom  short  of  apoplexy  arising  from  an  over- 
dose can  be  modified  by  bleeding  from  an  artery  (See  experiment 
No.  14,  drum  3,  Fig.  12). 

Artificial  respiration  according  to  the  Schafer  method  should  be 
employed  when  respiration  ceases.  As  a  last  resort,  the  chest  might 
be  opened,  and  direct  cardiac  massage  applied.  We  reestablished  the 
circulation  in  two  dogs  in  this  manner  after  giving  the  adrenalin.  The 
experiments  of  Senn  show  that  horses  are  more  severely  affected  by 
air  embolism  in  the  erect  than  in  the  horizontal  position,  and  therefore 
a  patient  should  be  kept  in  the  latter  position  during  the  effort  at 
resuscitation. 

In  animals  in  which  the  air  was  forced  in  under  pressure  it  was 
necessary  in  most  cases  to  apply  the  remedy  within  two  minutes,  but 
it  is  probable  in  many  clinical  cases  in  which  small  quantities  of  air  are 
aspirated  that  sufficient  time  will  elapse  between  the  accident  and  im- 
pending death  to  allow  of  some  attempt  to  save  them.  The  violent 
contraction  of  the  heart  muscle  that  results  from  the  introduction  of  a 
concentrated  adrenalin  chlorid  solution  into  its  cavities  is  the  most 
efficient  agent  that  we  found  for  restoring  a  circulation  embarrassed 
by  air  embolism. 

There  are  other  possible  postoperative  complications,  but  to  go  be- 
yond these  more  important  ones  would  draw  us  too  far  away  from  the 
main  purpose  of  this  book.  We  will  sum  up  by  repeating  that  the 
expeditious  operator  who  makes  careful  inquiry  into  the  functional 
condition  of  the  vital  organs,  who  conserves  the  vital  forces,  and  early 
establishes  elimination  will  have  a  relatively  limited  personal  acquaint- 
ance with  postoperative  complications. 

POSTOPERATIVE  PNEUMONIA. 

Postoperative  pneumonia  is  more  apt  to  occur  in  elderly  people. 
The  determining  cause  is  irritation  from  ether;  aspiration  of  mucus, 


HEMORRHAGE  AND  SHOCK.  63 

blood,  or  stomach  contents;  exposure  and  chilling  during  or  after  the 
operation;  or  sloughing  in  the  wound.  A  predisposing  cause  is  im- 
paired circulation.  The  quantity  of  ether  given  should  be  the  minimum 
necessary. 

Except  in  intestinal  obstruction,  there  is  little  danger  of  aspiration 
of  stomach  contents  if  the  patient's  head  is  turned  to  the  side  when  he 
vomits,  because  in  ordinary  vomiting-  the  pharyngeal  and  palatal  re- 
flexes are  present. 

The  function  of  the  lungs  is  augmented,  and  pulmonary  complica- 
tions are  rendered  less  likely,  by  placing  all  patients  in  a  sitting  posture 
in  bed  as  soon  as  they  come  from  under  the  anesthetic.  This  is  espe- 
cially important  with  weak  or  elderly  people.  It  is  not  practical  or 
necessary  with  infants  or  young  children.  All  should  be  well  pro- 
tected during  and  after  operation. 

EDEMA  OF  THE  LUNGS. 

This  is  a  rather  rare  postoperative  complication,  the  determining 
cause  of  which  may  be  ether ;  but  it  is  probable  that  a  weakened  heart's 
action  or  renal  disease  may  be  a  contributing  cause.  It  is  to  be  guarded 
against  in  the  same  manner  as  are  other  chest  complications.  It  is 
the  practice  of  some  to  give  all  patients  with  enfeebled  heart  several 
moderately  full  doses  of  digitalis  during  the  twenty- four  hours  preced- 
ing operation.  Twenty  minims  (1.25  cubic  centimeters)  of  the  tinc- 
ture is  what  we  ordinarily  use.  If  the  stomach  is  intolerant,  several 
doses  of  the  alkaloid  or  the  tincture  may  be  given  hypodermatically. 
A  milligram  of  strophanthin  (Bohringer)  may  be  given  once  intra- 
venously twenty-four  hours  before  operation.  Atropin,  if  given  early, 
will  sometimes  control  the  edema  after  it  has  set  in. 

SUPPRESSION  OF  URINE. 

This  is  best  avoided  by  assuring  kidney  function  before  operation 
and  limiting  the  quantity  of  ether.  Contrary  to  a  somewhat  popular 
practice,  patients  should  not  be  dehydrated  before  or  after  operation, 
but  may  receive  fluids  up  to  two  hours  before  the  operation,  and  by 
the  stomach  as  soon  after  as  water  can  be  swallowed.  We  also  avoid 
drastic  purges.  When  the  excretion  of  urine  is  deficient,  broken  doses 
of  calomel,  and  rectal,  subcutaneous,  or  intravenous  saline  infusions, 
and  possibly  digitalis  and  sweating,  are  indicated. 

ACETONURIA. 

Owing  to  a  derangement  in  metabolism,  there  is  sometimes  found  a 
condition  in  which  acetone,  oxybutyric  acid,  or  diacetic  acid  is  formed 


64  SURGERY  OF  THE  MOUTH  AND  JAWS. 

in  excess  and  liberated  into  the  circulation.  When  this  occurs  as  a 
postoperative  complication,  it  is  supposed  to  be  due  to  the  anesthetic, 
especially  chloroform.  It  causes  dryness  of  the  tongue,  excessive 
thirst,  and  asthenia,  and  may  be  recognized  by  a  sweet  odor  on  the 
breath  and  the  presence  of  acetone  or  diacetic  acid  in  the  urine.^ 

This  complication  is  comparatively  common  in  children,  and  is 
combated  by  withholding  protein  foods,  the  establishment  of  free  elim- 
ination, and  neutralizing  the  poison  by  giving  bicarbonate  of  soda  in 
medium-sized  doses — 2  grams,  or  'M)  grains,  every  six  hours. 


^Legal's  test  for  acetone:  One  fourth  of  a  test  tube  of  urine  is  treated  with 
a  few  drops  of  freshly  prepared,  somewhat  concentrated,  solution  of  sodium  nitro- 
prussid.  A  few  drops  of  acetic  acid  are  added  to  prevent  the  reaction  with 
creatinin,  and  the  mixture  is  then  rendered  alkaline  with  ammonic  or  sodic  hy- 
drate. The  mixture  gradually  develops  a  red  color,  which  increases  to  a  deep 
purple-red  color.  In  the  absence  of  acetone  the  red  or  purple  color  does  not 
form.  V.  Jakseh's  test  for  diacetic  acid:  To  the  urine  a  fairly  concentrated  so- 
lution of  perchlorid  of  iron  is  cautiously  added.  If  a  phosphatic  precipitate  forms, 
this  may  be  removed  by  filtration,  and  more  perchlorid  solution  is  added.  If  the 
Bordeaux  red  appears,  one  portion  of  the  urine  is  boiled,  while  another  is  treated 
with  sulphuric  acid  and  extracted  with  ether.  If  now  the  urine  that  has  been 
boiled  gives  no  reaction  with  the  perchlorid  of  iron  solution,  while  the  ethereal 
extract  shows  the  claret  color  with  the  iron  solution,  diacetic  acid  is  probably 
present,  particularly  if  the  urine  is  found  to  be  rich  in  acetone. 


CHAPTER  V. 

WOUNDS    AND    INJURIES    OF    THE    BONES    AND 

SOFT   PARTS.* 

In  this  chapter  will  be  considered  not  only  wounds  and  injuries  of 
the  bones  and  soft  parts,  but  general  surgical  principles  underlying 
the  care  of  all  wounds  and  injuries.  Injuries  may  vary  from  slight 
scratches  and  contusions  to  total  destruction  of  the  face,  from  scalds 
of  the  mucous  membrane  to  burns  involving  immense  loss  of  tissue, 
and  therefore  in  a  single  chapter  on  these  injuries  one  can  do  little 
more  than  deal  with  the  more  important  details. 

There  are  four  points  to  consider  in  dealing  with  any  wound  or  in- 
jury— namely,  (1)  the  extent  of  the  injury,  including  the  determina- 
tion of  the  structures  involved,  (2)  the  possible  presence  of  a  foreign 
body  in  the  wound,  (3)  the  probability  of  sepsis,  (4)  the  repair  of  the 
injury. 

WOUNDS. 

Extent  and  Character  of  the  Injury. — Injuries  resulting  from 
violence  or  force  may  be  classified  as  open  and  closed  wounds.  As  an 
example  of  the  former,  we  may  take  a  knife  cut  or  a  bullet  wound ;  of 
the  latter,  contusions  and  closed  fractures.  Open  and  closed  wounds 
differ  from  each  other  in  that  the  latter  are  but  little  liable  to  infection. 

From  their  clinical  significance,  open  wounds  have  been  divided 
into  four  classes: 

1.  Incised  Wounds. — These  are  wounds  in  which  the  tissues  are 
clean  cut  without  bruising,  and  in  which  the  depth  is  not  out  of  pro- 
portion to  the  surface  extent.  In  such  wounds  it  is  usually  easy  to 
determine  the  exact  tissues  involved.  There  is  little  likelihood  of  a 
foreign  body  remaining  undiscovered  in  their  depth,  and,  owing  to  the 
fact  that  vitality  of  the  tissues  is  but  little  impaired,  repair  without 
sepsis  is  probable. 

2.  Contused  Wounds. — These  wounds  differ  from  incised 
wounds  in  that  the  vitality  of  the  tissue  involved  may  be  greatly 
impaired,  and  that  sepsis  or  sloughing  will  be  a  possible  complica- 
tion. 

3.  Puncture  or  Stab  Wounds. — These  are  wounds  of  great  depth 
compared  with  their  surface  extent.  The  examination  of  such  an  in- 
jury may  leave  one  in  considerable  doubt  as  to  the  extent  of  the  dam- 


*For  further  discussion   of  treatment   of  wounds   and   injuries,   received   too   late   for 
incorporation  In  this  chapter,  see  appendix. 

65 


66  SURGERY  OF  THE  MOUTH  AND  JAWS. 

age.  If  clean  cut,  as  with  the  blade  of  a  knife,  there  is  less  probability 
of  sepsis  than  in  an  incised  wound ;  but  if  any  individual  structures  arc 
to  be  repaired,  or  if  there  is  a  foreign  body  to  be  removed,  enlargement 
of  the  original  wound  or  the  making  of  another  incision  will  probably 
be  necessary.  If  a  punctured  wound  is  made  with  a  dull  instrument, 
such  as  a  stick  driven  into  the  tissues,  the  element  of  contusion  is 
added.  In  this  case  sepsis  and  necrosis,  if  they  occur,  will  be  at  a 
depth,  and  may  necessitate  enlargement  of  the  wound  or  special  inci- 
sions for  drainage. 

4.  Gunshot  Wounds. — Under  this  heading  are  included  all  wounds 
made  by  war  projectiles.  The  large  proportion  of  gunshot  wounds 
of  the  head  in  the  present  war  renders  consideration  of  this  sub- 
ject of  special  importance.  The  following  projectiles  are  named 
in  the  order  of  frequency  with  which  they  have  produced  face 
and  jaw  injuries  in  the  present  war: 

Shrapnel  (most  common). 

Machine  gun  bullet. 

Rifle  bullet. 

Grenade. 

Trench  mortar. 

Shell. 

Wounds  Due  to  Shrapnel. — Shrapnel  consists  of  a  metal  casing 
containing  numerous  leaden  or  steel  bullets.  When  the  casing  ex- 
plodes the  bullets  are  scattered  in  a  forward  direction,  at  varying 
velocities,  and  when  striking  the  body,  produce  considerable  lacera- 
tion of  the  skin  and  soft  parts,  often  carrying  in  particles  of  cloth- 
ing, etc.  The  bullets  themselves  frequently  remain  embedded  in 
the  tissues.  When  they  strike  the  mandible  they  are  apt  to  shatter 
it. 

Machine  Gun  and  Rifle  Bullet  Wounds. — The  simple  rifle  bullet 
wound,  as  classically  described,  is  uncommon.  It  consists  of  a  small, 
clean  wound  of  entry,  and  a  larger  wound  of  exit,  the  amount  of 
injury  to  the  intervening  tissues  depending  upon  the  parts  involved. 
Under  actual  conditions  of  modern  warfare  the  nature  of  the  wound 
produced  is  greatly  modified  by  many  factors. 

The  axis  of  the  bullet  may  be  rotated  so  that  it  strikes  the  body 
at  an  angle  or  sidewise  owing  to  deflection  from  its  original  course 
by  striking  some  intervening  object.  It  may  have  been  altered  in 
shape  or  the  casing  may  have  been  broken.  After  entering  the  body 
the  bullet  may  be  flattened  or  otherwise  altered  in  shape  by  striking 
bone.  Any  of  these  circumstances  so  changes  the  shape  and  course 
of  the  bullet  as  to  produce  much  more  destruction  of  the  tissues  than 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS. 


67 


if  it  had  retained  its  original  form  and  direction  of  flight.  The  wound 
of  entrance  may  be  just  as  jagged  and  irregular  as  the  wound  of 
exit.  The  size  and  appearance  of  the  external  wounds  give  no  in- 
dication of  the  amount  of  injury  done  to  the  internal  structures.  With 
an  apparently  simple  external  wound,  there  may  be  very  extensive 
shattering  of  the  bone  beneath,  or  destruction  of  important  soft 
structures. 

Hand  Grenades. — These  are  small  explosive  bombs  which  inflict 
jagged  wounds. 


Fig.  13.  Showing  extensive  injury  from  a  shell  fragment  without  the  usual  amount 
of  destruction  of  the  facial  tissues.  (For  further  development  of  this  case,  see  Fig.  78.) 
— After  Hayes. 

Explosive  Shells. — These  are  made  of  steel  or  iron,  filled  with 
highly  explosive  material.  When  they  burst,  large,  irregular  frag- 
ments are  scattered  far  and  wide,  inflicting  extensive  jagged  wounds, 
or  the  wound  might  be  clean  cut  from  a  sharp  fragment. 

Infection  from  the  earth,  clothing,  etc.,  is  always  carried  into 
the  wounds,  which,  together  with  the  mechanical  destruction  of  the 


68  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tissues,  renders  them  the  most  formidable  and  terrible  of  all  war 
injuries  (Fig.  13). 

In  all  types  of  gunshot  wounds  of  the  face  and  jaws,  infection 
is  practically  always  present,  there  is  laceration  of  the  soft  tissues, 
shattering  of  the  bone,  frequently  with  extensive  loss  of  substance, 
fracturing  of  teeth,  which  may  be  carried  to  distant  points  and  em- 
bedded in  the  soft  parts,  such  as  the  tongue  and  floor  of  the  mouth, 
and  frequently  retention  of  the  projectile  in  the  tissues. 

Closed  Vv/^ounds. — Closed  injuries  may  be  confined  to  the  soft 
parts,  including  the  periosteum,  in  which  case  they  are  called  con- 
tusions; or  they  may  involve  a  bone,  constituting  a  fracture.  Burns 
which  are  destructive  of  tissue,  due  to  thie  action  of  heat,  light, 
electricity,  or  caustics,  will   be   considered   separately. 

The  method  of  determining  the  structures  injured  should  be  both 
anatomical  and  physiological,  and  will  vary  with  the  character  of  the 
injury.  If  the  eye  or  the  finger  can  penetrate  a  certain  depth  into  an 
incised  wound,  a  fairly  accurate  estimate  of  the  damage  can  be  made 
on  purely  anatomical  grounds.  Again,  if  a  probe  can  be  passed  into 
a  punctured  wound  a  certain  depth  and  direction,  we  may  be  able  to 
say  that  certain  structures  are  injured,  but  to  determine  if  other  neigh- 
boring structures  have  escaped,  we  may  have  to  resort  to  the  examina- 
tion of  function. 

A  completely  severed  muscle  will  lose  its  function.  An  injury  of 
a  motor  nerve  will  cause  a  paralysis  of  its  muscle  or  muscles,  an  injury 
of  a  sensory  nerve  will  cause  anesthesia  or  loss  of  taste,  an  injury  to  a 
blood  vessel  will  cause  hemorrhage,  and  an  injury  of  a  salivary  duct 
will  be  evidenced  by  leakage  of  saliva.  In  this  manner,  by  a  careful 
examination,  it  is  usually  possible  to  form  an  accurate  estimate  of  the 
anatomical  damage. 

Possible  Presence  of  a  Foreign  Body. — The  possible  presence 
of  a  foreign  body  in  a  wound  may  be  determined  by  the  sum  of  several 
investigations :  First,  the  history  of  the  injury  and,  if  possible,  an 
examination  of  the  instrument  with  which  it  was  inflicted.  If  with 
a  stick  or  knife,  the  determination  that  the  point  is  missing  will  lead 
to  the  surmise  that  it  may  be  in  the  tissues.  If  a  bullet  wound  shows 
no  hole  of  exit,  the  same  conclusions  may  be  reached ;  but  the  presence 
of  a  wound  of  exit  does  not  exclude  the  possibility  of  a  part  of  a  lead 
bullet  or  pieces  of  clothing  or  misplaced  bone  fragments  remain- 
ing. Feeling  with  the  finger  or  probe  may  show  the  presence  of  a 
foreign  body,  but  it  is  difificult  to  exclude  it  with  the  latter.  Lastly, 
the  presence  or  absence  of  bodies  that  are  impenetrable  to  the  x-ray 
may  be  determined  by  its  use. 

Before  inserting  a  probe  or  anything  else  into  a  fresh  wound,  one 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS.  69 

should  stop  for  a  moment  to  consider  whether  the  act  will  be  pro- 
ductive of  more  good  than  harm.  It  is  often  difficult  to  follow  the 
course  of  a  deeply  punctured  wound  in  soft  tissue  with  a  probe,  and 
one  who  attempts  to  do  so  will  seldom  be  certain  that  he  is  following 
the  track  of  a  wound  and  not  dissecting  the  tissues.  Further,  unless 
the  probe  and  the  mouth  of  the  wound  are  clean,  he  may  carry  into 
the  depths  an  agency  of  infection  that  failed  to  penetrate  with  the  origi- 
nal injury.  The  same  holds  true,  but  to  much  less  degree,  with  sinuses 
and  abscess  cavities.  We  do  not  mean  this  as  a  condemnation  of 
probes  and  probing,  both  of  which  have  a  distinct  place  in  surgical 
operations,  but  as  a  condemnation  of  the  indiscriminating,  thoughtless 
use  of  probes. 

A  foreign  body  deep  in  the  tissues  may  sometimes  be  located  by 
palpation,  both  by  the  objective  resistance  transmitted  to  the  finger  of 
the  examiner  and  by  the  subjective  pain  or  discomfort  caused  by  a 
certain  manipulation  or  manipulations.  Foreign  bodies  can  be  approxi- 
mately located  by  the  x-ray  by  radiographing  from  two  different  sur- 
faces and  determining  the  point  of  intersection  at  which  the  foreign 
body  is  situated.  Unless  they  are  very  difficult  of  access,  they  should 
be  removed.  If  rather  inaccessible,  their  location  and  character  will 
determine  our  course.  Hard  structures — such  as  bullets,  bits  of  knives 
or  slate  pencils — often  remain  in  the  tissues  without  causing  further 
disturbance,  and  it  may  be  better  to  wait  for  positive  indications  for 
their  removal  than  to  do  greater  damage  by  the  immediate  attempt. 
When  it  is  seen  that  a  foreign  body  is  the  focus  of  suppuration  or  the 
cause  of  nerve  irritation,  it  should  be  sought,  and  removed  if  found. 
It  is  not  well  to  attempt  to  find  a  deeply  seated  or  a  very  small  object 
by  cutting  down  to  its  supposed  situation  through  a  straight  incision. 
Success  is  more  apt  to  crown  the  effort,  and  less  damage  will  probably 
be  done,  if  a  semilunar  incision  is  made  through  the  skin  and  fascia 
and  a  flap  turned.  This  will  give  room  for  examining  and  for  dis- 
secting between  the  more  important  structures  as  they  are  encoun- 
tered. 

Probability  of  Sepsis. — Infection  of  a  wound  depends  on  the 
lodgment  of  pathogenic  bacteria  in  the  wound  in  sufficient  numbers 
to  overcome  the  resistance  of  the  tissues.  The  probability  of  infec- 
tion will  depend  on  the  location  of  the  injury,  character  of  the  injiu\v. 
manner  of  its  infliction,  and  time  which  has  elapsed  before  treatment. 

Clean-cut  wounds  are  less  liable  to  infection  than  open  contused 
wounds,  and  punctured  wounds,  unless  contused,  are  more  apt  to  heal 
kindly  than  even  incised  wounds.  Wounds  that  contain  a  foieign 
body — especially  such  as  bits  of  stick,  dirt,  or  clothing — are  more  apt 
to  be  infected  than  those  that  do  not,  and  wounds  that  have  been  ex- 


70  SURGERY  OF  THE  MOUTH  AND  JAWS. 

posed  for  hours  are  less  liable  to  remain  clean  than  those  that  are  im- 
mediately treated. 

In  the  present  war,  owing  to  the  frequency  of  lacerated  wounds, 
the  prolonged  exposure  before  treatment  is  instituted,  and  the  viru- 
lence of  the  bacteria  found  in  the  highly  fertilized  earth  and  on 
the  soldier's  clothes,  it  is  safer  to  consider  every  open  wound  as 
infected  and  treat  it  accordingly.  Even  in  civil  practice  all  ac- 
cidental wounds,  and  probably  all  operative  wounds,  contain 
the  bacteria  of  sepsis,  most  commonly  Staphylococcus  alhiis.  As 
stated  before,  they  must,  however,  be  present  in  sufficient  numbers  to 
be  able  to  overcome  the  tissue  resistance  before  they  can  cause  suppura- 
tion. There  are  three  ways  in  which  they  can  be  present  in  great 
numbers:  (1)  by  being  introduced  in  quantity  with  the  infliction  of 
the  wound,  (2)  by  being  continuously  introduced  into  an  open  wound, 
(3)  by  having  considerable  media  in  the  wound — blood  clot,  serum, 
devitalized  tissue,  catgut,  etc. — in  which  they  can  multiply  unmolested 
until  their  numbers  have  sufficiently  increased  and  they  have  elaborated 
enough  toxin  to  enable  them  to  attack  the  living  tissues. 

It  is  probable  that  the  first  contingency  is  comparatively  rare,  and 
that  the  majority  of  clean-cut  wounds  would,  if  immediately  approxi- 
mated, heal  by  what  is  clinically  known  as  first  intention.  In  the  face 
and  mouth  the  blood  supply  is  so  abundant  that  the  tissue  resistance 
to  infection  is  very  high,  and  immediate  suture  of  wounds  is  usually 
followed  by  success. 

The  third  method  of  wound  infection — the  development  of  the  bac- 
teria in  culture  media  present  in  the  wound — is  to  be  avoided  by  atten- 
tion to  the  following  points :  removal  of  devitalized  tissue,  avoidance 
of  porous  sutures  and  ligatures,  closing  of  the  wound  without  dead 
spaces,  and  providing  drainage.  To  this  end,  when  possible,  all  hem- 
orrhage is  to  be  controlled.  Shreds  of  tissue  may  be  removed  with 
knife  or  scissors,  or  the  wound  may  be  dressed  antiseptically  and  su- 
tured later,  when  all  damaged  tissue  has  either  recovered  or  sloughed. 
This  is  the  principle  upon  which  simple  packing  of  the  wound, 
Wright's  hypertonic  salt  solution,  the  Carrel-Dakin,  and  modifications 
of  the  latter  by  Dakin,  Lee,  LeConte,  Sweet  and  Hendricks,  and 
other  methods  of  temporary  open  treatment  of  wounds  are  based. 
In  suturing,  the  cut  surface  should  be  approximated  to  the  full  depth 
of  the  wound.  If  this  is  not  done,  a  dead  space  may  become  dis- 
tended with  fluid  that  will  serve  as  culture  medium  for  germs.  In 
wounds  that  are  liable  to  become  infected,  it  is  customary  to  pro- 
vide drainage  to  carry  off  the  wound  secretions.  This  may  be  done 
in  two  ways.  If  it  is  a  deeper  portion  of  the  wound  that  is  to  be 
drained,  some  substance — as  a  hollow  tube,  strands  of  horsehair,  silk 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS.  71 

or  silkworm  gut,  a  folded  slip  of  rubber  dam,  or  some  other  device 
— is  carried  from  the  point  to  be  drained  to  the  surface,  either  out 
through  the  wound  or  through  an  extra  stab  wound.  Drainage  from 
the  superficial  part  of  a  wound  may  be  accomplished  by  only  loosely 
approximating  the  cut  surfaces,  so  that  the  secretions  may  exude 
from  between  them.  Tight  suturing  not  only  interferes  with  drain- 
age of  the  wound,  but,  by  limiting  the  blood  supply,  lessens  the  tissue 
resistance.  Even  where  infection  of  a  wound  of  the  face  or  mouth 
is  well  established,  unless  it  is  of  a  virulent,  spreading  character, 
union  will  usually  follow  suture  if  drainage  is  not  obstructed. 

It  is  somewhat  customary  to  advise  the  attempt  to  clean  fresh 
wounds  before  suturing  them.  Without  going  into  the  rationale  of  the 
procedure  in  wounds  in  general,  it  may  be  well  to  state  that,  with  the 
exception  of  the  removal  of  gross  particles  and  torn  shreds  of  tissue, 
which  really  constitute  foreign  bodies,  we  never  make  any  systematic 
attempt  to  clean  wounds  of  the  face  and  mouth  by  washing  them. 
Though  there  is  much  laboratory  evidence  as  to  the  evils  of  using 
irritants  upon  cut  surfaces,  still  there  is  also  much,  and  old,  clinical 
evidence  that  the  use  of  tincture  of  iodine,  or  strong  carbolic  acid 
followed  by  alcohol,  in  a  fresh  wound,  may  inhibit  bacterial  growth 
without  damaging  the  tissues  to  the  extent  of  preventing  union  if 
sufficient  drainage  is  provided. 

Where  practicable,  the  skin  edges  should  be  cleaned  with  normal  sa- 
line solution,  ether,  alcohol,  or  tincture  of  iodin.  We  usually  use  the 
latter  in  one  half  or  one  third  of  its  normal  strength  for  all  skin  prepara- 
tions. We  are  convinced  that  any  attempt  to  wash  bacteria  from  a 
fresh  cut,  besides  impairing  the  vitality  of  the  tissues,  is  more  apt  to 
have  the  reverse  effect. 

In  dealing  with  infected  wounds  of  the  face  and  mouth,  it  may  be 
expedient  to  wait  a  few  days  before  suturing.  By  this  time  a  wall 
of  active  granulations  has  grown  in  the  cut  surface,  and  necrotic  parts, 
possibly  with  minute  foreign  bodies,  have  been  thrown  off.  The  factor 
that  is  disadvantageous  in  delayed  suture  is  the  contraction  that  occurs 
in  the  developing  granulations,  which,  though  it  lessens  the  wound 
surface,  distorts  the  relations  of  the  cut  structures,  drawing  the  skin 
toward  the  depth  of  the  wound  and  causing  the  retraction  of  loose 
flaps. 

If  it  is  seen  that  suppuration  is  developing  in  the  depth  of  a  sutured 
wound,  drainage  must  be  established ;  but  on  the  face  and  in  the  mouth 
it  is  seldom  advisable  to  recklessly  remove  all  sutures.  Preferably, 
drainage  from  between  the  sutures  should  be  encouraged  by  inserting 
a  pair  of  pointed  forceps  into  the  wound,  gently  opening  them,  and 
removing  a  suture  here  and  there  as  necessary.     It  is  only  when  an 


73  SURGERY  OF  THE  MOUTH  AND  JAWS. 

infection  is  of  a  fulminating  character,  or  when  there  is  a  great  sys- 
temic reaction,  that  it  is  necessary  to  lay  the  wound  open  to  its  full 
extent.  Even  then  the  infection  can  often  be  controlled  by  the  use  of 
the  ice  bag,  but  in  suspected  gas  bacillus  or  other  virulent  infection 
this  should  not  be  attempted. 

Men  who  confine  their  practice  to  the  mouth  cavity  become  so  ac 
customed  to  see  infected  wounds  and  abscesses  that  result  from  tooth 
infections  heal  with  relatively  slight  general  disturbance,  that  they 
may  sometimes  lose  sight  of  the  fact  that  infections  do  not  always 
remain  local,  and  that  serious  illness  or  death  may  result  from  appar- 
ently most  trivial  causes.      (See  Infections,  page  32.) 

In  the  consideration  of  wound  infection,  we  have  confined  ourselves 
to  the  mention  of  sepsis,  which  usually  means  an  infection  with  bac- 
teria that  causes  suppuration.  There  are  bacteria  of  other  diseases 
that  may  gain  access  through  wounds,  but  their  development  is  de- 
pendent on  the  same  conditions.  One  of  these  diseases  requires  par- 
ticular mention,  and  that  is  tetanus.  The  bacillus  of  tetanus  is  rather 
broad  in  its  distribution,  and  is  found  particularly  in  manure,  street 
dirt,  and  the  surface  earth.  Its  entrance  into  wounds  that  have  been 
inflicted  by  an  object  that  has  been  in  contact  with  the  ground  must  be 
relatively  common.  The  rusty  nail  that  causes  tetanus  does  so,  not 
because  it  is  rusty,  but  because  it  carries  tetanus  bacilli  and  because 
it  inflicts  a  deep,  lacerated  wound.  For  the  development  of  lockjaw 
it  is  necessary  that  the  bacilli  of  tetanus  develop  in  the  wound,  and 
they  will  not  develop  in  the  wound  unless  favorable  conditions  arc 
found.  It  is  not  even  necessary  that  the  wound  be  deep,  as  scabs  and 
slough  may  furnish  the  protection  needed  for  the  development  of 
bacilli  that  lie  under  them. 

If  the  clinical  symptoms  of  tetanus  become  manifest  within  six 
days  from  the  date  at  which  the  bacilli  have  actually  entered  the 
tissues,  there  is  little  that  can  be  done  to  avoid  a  fatal  issue.  But 
its  development  can  nearly  always  be  prevented  by  the  early  injec- 
tion of  a  prophylactic  dose  of  tetanus  antitoxin,  and  therefore,  in 
every  case  of  a  wound  that  has  been  received  in  the  street  or  on 
the  ground,  or  inflicted  with  an  instrument  that  has  been  in  con- 
tact with  the  ground,  500  to  1500  units  of  tetanus  antitoxin  should 
be  injected  as  soon  afterward  as  possible.  Tupper  and  the  writer 
have  been  following  this  procedure  for  the  past  nineteen  years,  and 
neither  of  us  has  since  had  a  case  of  tetanus  develop  from  a  wound 
of  which  we  had  the  original  care. 

In  the  present  war  the  importance  of  repeated  doses  of  tetanus 
antitoxin  has  been  demonstrated.  The  protection  lasts  only  about 
two  weeks  and  does  not  destroy  the  bacilli  in  the  wound  itself.     It 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS.  73 

is  now  customary,  in  suppurating  wounds,  to  give  a  smaller  dose  each 
two  weeks  until  the  wound  heals. 

Gas  Bacillus  Infection  (Gas  Gangrene). — Another  form  of  in- 
fection requiring  special  mention  because  it  occurs  commonly  in 
wounds  during  the  present  war,  is  that  caused  by  a  group  of  bacteria 
the  commonest  of  which  is  the  bacillus  aerogenes  capsulatus  of  Welch, 
also  known  as  the  bacillus  perfringens.  When  a  wound  is  infected 
with  this  organism,  the  tissues  become  swollen,  and  take  on  a  mot- 
tled, purphsh  color.  There  is  distinct  crepitation,  due  to  the  forma- 
tion of  gas,  associated  with  a  thin  brownish  discharge  from  the 
wound.  Gangrene  of  the  soft  tissues  is  due  to  interference  with 
nutrition  by  pressure  of  the  exudate  and  gas  formation.  If  not 
checked  in  its  early  stages,  the  destructive  process  is  progressive, 
and  involvement  of  an  entire  limb  may  result.  The  general  sys- 
temic effect  of  the  toxin  also  may  be  rapidly  fatal. 

The  organism  seems  to  thrive  only  in  dead  tissue  or  tissue  that 
has  been  changed  by  its  toxin  and  not  exposed  to  the  air,  its  mode 
of  attack  being  most  frequently  as  follows :  It  first  finds  lodgment 
in  necrotic  tissue  in  a  lacerated  wound.  As  the  organisms  develop 
they  evolve  gas  and  toxins,  which  form  intercellular  pressure  and 
poisoning,  devitalize  the  surrounding  healthy  tissue,  which  in  tuni 
serves  as  a  medium  for  the  development  of  the  bacilli,  which  cause 
gangrene  of  the  attacked  area.  This  vicious  circle  continues  until 
the  patient  is  overcome  by  the  absorbed  toxins  or  septicemia. 

Local  Treatment  consists  first  of  thorough  cleansing  of  possibly 
infected  wounds.  The  Carrel-Dakin  treatment  may  be  efifective  in 
doing  this.  When  the  tissues  are  attacked,  free  incision  is  indicated 
both  for  drainage  and  to  relieve  the  pressure,  followed  by  bathing  in 
antiseptics,  plain  water  or  oxygenated  solutions.  Solutions  of  hydro- 
gen peroxide  have  been  injected  into  the  tissues.  Free  incisions  have 
given  better  results  than  amputations.  The  use  of  a  prophylactic 
serum  (Bull  and  others)  seems  to  hold  some  promise  about  the  tissues 
of  the  face  and  base  of  the  skull.  Free  drainage  of  infected  muscles 
is  difficult  on  account  of  their  bony  relations.  Therefore,  before  the 
suturing  of  any  wound,  the  possibility  of  gas  infection  must  be  care- 
fully considered. 

Healing  of  Wounds. — Wounds  heal  by  means  of  a  hyperactivit}' 
of  the  contiguous  tissue.  The  first  change  in  the  tissues  around  the 
wound  is  a  contraction  of  the  cut  blood  vessels,  which  tends  to  stop 
the  bleeding.  Next  there  is  a  dilatation  of  the  vessels  with  increased 
blood  supply,  and  an  exudation  of  plasma  and  white  cells.  Later  there 
is  an  increase  of  the  fixed  tissue  cells  and  a  growth  of  new  blood  ves- 
sels.    This  growth  or  increase  in  the  fixed  tissue  cells  is  largely  con- 


74  SURGERY  OF  THE  MOUTH  AND  JAWS. 

fined  to  the  connective  tissues.  Besides  these,  there  are  very  few  of 
the  body  tissues  that  have  the  power  of  reproducing  themselves. 
Among  the  exceptions  are  the  surface  epithelial  cells  of  the  skin  or 
mucous  membrane.  The  endothelial  lining  cells  of  blood  vessels  and 
lymphatics  and  the  axis  cylinders  of  nerves  that  still  retain  their  con- 
nection with  nerve  ganglia  are  capable  of  reproduction. 

The  growth  of  the  connective  tissue  cells  forms  an  embryonal  tis- 
sue called  granulations — the  red  velvety  surface  that  is  seen  in  every 
open  healing  wound.  This  granulation  tissue  ultimately  undergoes 
changes  by  which  it  is  transformed  into  scar.  It  is  almost  entirely  by 
means  of  scars  that  bind  together  the  contiguous  tissues  that  wounds 
are  healed.  Bone  granulations  become  impregnated  with  lime  salts 
and  go  through  a  series  of  changes,  which  may  ultimately  result  in  true 
bone  tissue. 

It  has  been  found  convenient  to  speak  of  the  healing  process  as 
divided  into  two  kinds — that  which  takes  place  in  a  clean,  approxi- 
mated wound,  and  that  which  occurs  in  an  open  or  infected  wound. 
The  first  is  called  healing  by  first  intention,  or  primary  healing,  and 
the  second  is  spoken  of  as  healing  by  second  intention,  or  healing 
by  granulation.  Though  the  healing  in  these  cases  dififers  clinically, 
still  essentially  it  is  identical. 

When  the  surfaces  of  a  clean  wound  are  held  in  apposition,  they 
are  first  agglutinated  by  the  wound  secretions  and  later  are  perma- 
nently united  by  granulation,  which  turns  to  scar.  In  open  and  sup- 
purating wounds  the  surfaces  cannot  be  immediately  agglutinated  by 
the  wound  secretions,  nor  can  the  granulations  grow  directly  across 
the  gap  from  one  cut  surface  to  another. 

Granulation  obliterates  an  open  wound  in  the  following  way :  As 
granulation  tissue  ages,  its  deeper  and  older  layers  contract.  In  a 
wound  in  the  soft  tissues  this  contraction  lessens  both  the  surface  area 
and  the  depth  by  drawing  the  surrounding  and  underlying  tissues  into 
the  defect.  When  a  wound  has  healed,  the  scar  will  be  much  smaller 
than  the  original  defect,  and  it  is  due  to  this  contraction  of  the  scar 
that  the  surface  of  a  healed  wound  is  often  depressed.  It  is  because 
the  surrounding  tissues  cannot  be  drawn  into  the  defect  that  deep  cavi- 
ties in  bones  heal  very  slowly,  if  at  all. 

When  the  granulation  at  the  edge  of  the  wound  reaches  the  level 
of  the  surface  epithelium,  the  latter  ordinarily  begins  to  grow  over  and 
cover  the  granulation,  so  that  most  surface  scars  are  covered  with 
epithelium. 

Healthy  granulations  are  of  a  bright-pink  color  and  of  a  velvety 
appearance.  They  are  very  rich  in  blood  vessels,  which  consist  of 
newly  formed  capillary  loops,  and  it  is  on  account  of  these  that  granu- 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS.  75 

lations  bleed  so  free! v  when  injured.  Even  healthy  granulations  are 
continuously  bathed  in  a  slight  excretion  of  serum  containing  some 
white  cells.  The  character  of  the  granulation  may  be  modified  by 
either  local  or  general  conditions.  Local  infections,  mechanical  irrita- 
tions, a  constitutional  disease,  or  general  depression,  all  have  a  malign 
effect  on  the  healing  process,  and  it  is  to  one  of  these  that  an  abnormal 
or  unhealthy  condition  of  granulations  is  due.  A  fair  estimate  of  the 
local  or  general  condition  can  frequently  be  gained  from  the  appear- 
ance of  the  granulations. 

As  granulation  tissue  matures,  it  is  converted  into  scar.  This  is 
a  contractile  fibrous  tissue,  from  which  eventually  most  of  the  blood 
vessels  disappear.  As  a  result  of  contraction,  a  normal  scar  is  usually 
much  smaller  than  the  original  wound.  Owing  to  its  poor  blood 
supply,  it  is  whiter  than  the  surrounding  tissue.  While  scar  naturally 
tends  to  contract,  it  cannot  do  so  against  any  great  resistance.  It  is 
not  a  strong  tissue,  and  will  stretch  when  a  continuous  strain  is  put 
on  it.  This  is  why,  in  some  situations,  scars  may  increase  in  breadth 
and  length.  Incisions  on  the  face  and  neck  should,  when  possible,  be 
made  in  the  direction  of  the  natural  cleavage  of  the  skin.  When  this 
is  done,  the  resulting  scar  will  always  tend  to  become  narrower.  When 
an  incision  is  made  across  the  line  of  skin  cleavage,  the  scar  stretches 
with  age.  Kocher,  from  observing  the  results  of  drainage  incisions 
in  various  parts  of  the  body,  has  worked  out  the  cleavage  lines  to  which 
incisions  should  correspond. 

The  time  after  injury  at  which  a  scar  contracts  and  the  blood  ves- 
sels are  obliterated  is  somewhat  variable,  and  it  may  be  long  delayed. 
A  scar  that  continues  to  increase  in  size  and  remains  red  long  after 
the  wound  has  healed  is  called  a  keloid  scar,  which  is  somewhat  dif- 
ferent from  the  true  keloid  tumor.  Some  individuals  have  a  distinct 
tendency  to  form  keloid  scars,  and  sometimes  a  hint  of  this  condition 
can  be  had  from  observing  the  scars  resulting  from  former  wounds. 

Once  after  removing  a  large  dermoid  cyst  from  the  floor  of  the 
mouth  through  a  transverse  incision  under  the  chin,  the  scar  was 
hardly  visible  at  the  end  of  a  week.  The  patient,  a  girl,  was  sent 
home  with  the  assurance  that  the  scar  wound  would  never  show.  A 
year  later  she  returned  with  a  red  corded  keloid  scar,  5  millimeters  high 
and  almost  1  centimeter  wide.  Investigation  showed  that  she  had  sev- 
eral similar  scars  on  the  thigh,  resulting  from  boils  that  occurred  years 
before.  A  knowledge  of  this  at  the  time  of  the  operation  would  have 
saved  us  from  embarrassment. 

Any  chronic  infection  or  constitutional  disease  may  hamper  or  de- 
lay the  healing  of  wounds.  In  dealing  with  troops  from  the  South,  the 
possibility  of  malaria  and  hookworm  should  be  borne  in  mind. 


76  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Treatment  of  Wounds. — The   ultimate    result    from   an    injury 

will  depend  on  the  extent  of  the  injury,  the  presence  and  character 
of  infection,  the  reaction  of  the  tissues,  and  the  treatment  it  receives. 
Except  shreds  and  absolutely  detached  pieces  of  bone,  or  a  tooth  or 
piece  of  bone  that  prevents  the  proper  approximation  of  a  fracture, 
no  injured  tissue  should  be  removed  from  the  face  until  it  is  absolutely 
certain  that  it  cannot  recover  its  vitality.  This  is  particularly  im- 
portant in  regard  to  all  attached  fragments  of  bone.  The  blood  sup- 
ply of  the  face  is  particularly  rich,  and  the  tissues  recover  and 
wounds  heal  in  a  way  that  has  no  parallel  in  the  rest  of  the  cutaneous 
surface  of  the  body.  On  the  other  hand,  the  loss  of  even  small 
quantities  of  tissue,  especially  bone,  may  cause  deformities  that  can 
never  be  entirely  corrected.  If  the  wound  has  become  infected,  the 
repair  of  special  structures  may  have  to  be  deferred  until  the  infection 
has  been  controlled. 

The  first  point  in  the  treatment  of  a  recent  wound  is  the  control 
of  the  hemorrhage,  if  this  be  present. 

In  recent  wounds  all  important  structures  should  be  repaired,  and 
blood  vessels,  with  the  occasional  exception  of  the  important  veins, 
should  be  ligated  or  twisted.  As  stated  under  hemorrhage  (page  49), 
veins  may  occasionally  be  sutured.  Motor  nerves  should  be  united  by 
fine  sutures.  Injuries  to  salivary  ducts  are  treated  by  making  pro- 
vision for  the  saliva  to  flow  from  the  cut  duct  into  the  mouth  (Salivary 
Fistula,  Chap.  XXXV).  Muscles  that  are  completely  divided  should 
be  sutured,  but  it  is  not  always  necessary  that  they  be  sutured  individ- 
ually. Lastly,  the  skin  or  mucous  membrane  should  be  accurately 
sutured.  Where  no  special  structures  other  than  muscles  are  involved 
in  wounds  of  moderate  depth,  the  deep  structures  and  the  skin  or 
mucous  membrane  may  be  all  united  by  the  same  sutures. 

Wounds  should  be  closed  in  such  a  manner  as  to  exclude  dead 
spaces,  in  which  the  tissue  fluids  and  blood  may  collect.  This  is  an 
important  preventive  against  sepsis. 

Under  the  present  war  conditions,  the  percentage  of  wounds  that 
can  be  immediately  closed  is  relatively  small,  but  it  is  probable  that 
most  wounds  of  the  face  seen  within  the  first  twelve  hours  may  be 
closed  with  comparative  safety,  after  thorough  iodinization,  by  a  few 
approximating  sutures  with  full  provision  for  drainage. 

Billroth  made  an  observation  which  has  somewhat  generally 
been  lost  sight  of,  namely,  that  it  is  bad  practice  to  sew  up  a  wound 
in  the  floor  of  the  mouth,  especially  one  of  the  larger  wounds  that 
result  from  excision  of  the  jaw  or  tongue.  It  predisposes  to  sepsis 
and  secondary  hemorrhage.     Our  earlier  observations  conform  with 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS.  77 

Billroth's.  Fo'r  some  time  we  have  made  it  a  practice  never  to  sew 
up  the  floor  of  the  mouth  after  a  resection,  but  put  in  a  Mikuhcz 
pack  of  iodoform  gauze  and  balsam  of  Peru,  which  will  usually  make 
a  water-tight  joint  and  remain  in  place  a  week  or  ten  days  without 
changing.  If  in  planning,  the  transverse  incision  is  made  below  the 
level  of  the  hyoid  bone,  then  it  is  probable  that  the  fistula  will  close 
spontaneously.  If  not,  it  is  later  closed  by  suture  after  dissecting 
out  the  granulating  tissue.  In  this  secondary  suture  there  does  not 
seem  to  be  the  same  danger  of  severe  sepsis  and  secondary  hemorrhage 
as^  when  the  wound  is  sutured  primarily. 

Extensive  loss  of  tissue  on  the  face  is  to  be  replaced  by  plastic  op- 
eration (Chap.  XIX).  It  is  not  necessary  to  wait  until  the  wounds 
have  entirely  healed  before  undertaking  to  do  this,  but  one  should  be 
guided  by  what  is  to  be  expected  from  the  healing  process,  unassisted 
by  any  flap  operation.  The  defects  from  absolute  loss  of  tissue  become 
smaller  as  granulation  and  scarring  progresses,  but  undermined  flaps 
retract  so  that  the  defect  will,  for  a  time,  enlarge.  Later  these  will  be 
drawn  toward,  but  not  exactly  to,  their  original  position.  According  to 
the  condition  of  the  wound,  the  repair  of  these  defects  may  be  under- 
taken immediately,  or  as  soon  as  the  wound  presents  a  clean  granulating- 
surface  and  the  general  condition  of  the  patient  warrants. 

BURNS. 

Burns  are  really  a  variety  of  open  wounds.  Deep  burns  contain 
a  foreign  body — the  burnt  tissue.  Burns  are  classified  according  to 
the  depth  to  which  the  tissue  is  destroyed.  The  disfigurement  result- 
ing from  a  burn  is  dependent  on  the  depth  and  extent,  and  also  on  the 
amount  of  infection  that  followed.  The  heavy  scarring  often  seen 
after  a  severe  burn  is  the  result  of  an  excessive  inflammatory  process, 
due  to  a  prolonged  infection.  Superficial  burns,  though  less  destruc- 
tive, are  more  painful  than  deep  ones.  The  pain  should  be  controlled, 
which  may  be  done  more  or  less  efifectually  by  cold,  moist  applica- 
tions or,  better  still,  on  the  skin  surface  by  the  application  of  a  sat- 
urated solution  of  picric  acid  in  water,  applied  with  cloths  for  several 
hours.  The  picric  acid  solution  will  relieve  the  pain  almost  instantly,  but 
the  disadvantage  is  of  staining  the  skin  yellow.  With  extensive  burns, 
shock  is  often  a  serious  complication    (Treatment  of   Shock,   p.   5S). 

A  burn  is  an  aseptic  wound,  and  its  aseptic  character  should  be  pre- 
served. It  is  not  aways  possible  to  do  this  with  dry  dressing,  as  in- 
fection may  occur  at  the  junction  of  the  skin  and  the  slough.  The 
skin  always  contains  the  organisms  of  sepsis.  The  application  of  a 
pack  of  alcohol  or  of  a  5  per  cent  colloidal  silver  is  non-irritating  and 
non-toxic,    and   will   render   the   eschar   antiseptic. 


78  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Lately  the  old  idea  of  applying  oil  as  a  protective  dressing  has 
been  superseded  by  the  application  of  a  film  of  paraffin  to  the  burn.^ 
The  surface  of  the  wound  is  cleaned  and  dried — this  latter  may  be 
accomplished  by  applying  first  alcohol  and  then  acetone — and  then 
a  coating  of  Hquid  petrolatum  is  applied  with  a  brush  or  a  spray. 
This  is  followed  by  a  thin  layer  of  cotton  which  is  saturated  with 
the  hot  wax.  A  gauze  dressing  and  bandage  complete  the  dressing 
after  the  wax  has  hardened.  This  dressing  is  repeated  daily  after 
cleaning  and  drying  the  surface  of  the  burn.  It  is  claimed  that  by 
this  form  of  treatment  rehef  from  pain  is  immediate  and  healing 
is  rapid. 

If  the  full  thickness  of  the  skin,  with  its  glands,  has  been  de- 
stroyed, the  resulting  defect  should  be  remedied  by  skin  grafting  or 
by  flap  operation   (page  249). 

The  pain  of  slight  scalds  of  the  mouth  is  partially  relieved  by  alka- 
line antiseptic  washes  and  cold  applications.  As  a  rule,  they  need 
little  other  treatment.  Severe  scalds  of  the  mouth  or  pharynx,  such  as 
occur  with  children  and  insane  people,  are  very  serious,  and  liable  to 
be  fatal  from  edema  of  the  glottis.  The  acute  swelling  in  the  mouth 
is  to  be  relieved  by  the  application  of  ice,  or  incisions,  especially  into 
the  dorsum  of  the  tongue,  and  tracheotomy  should  be  done  if  edema 
of  the  glottis  threatens. 

In  burns  that  result  from  chemical  caustics,  the  chemical  agent  re- 
maining in  the  wound  should  be  neutralized,  and  then  the  injury  should 
be  treated  on  general  lines.  Carbolic  acid  is  neutralized  by  alcohol  or 
whiskey,  lye  by  vinegar  and  oils  (fine  olive  oil  does  not  saponify  read- 
ily), and  all  acids  by  an  alkali,  usually  the  bicarbonate  of  soda,  prefera- 
bly in  solution. 

X-ray  burns,  which  occasionally  appear  after  prolonged  or  repeated 
exposure  to  the  ray,  especially  from  the  soft  tubes  that  are  used  for 
treatment,  or  from  exposure  to  radium  salts,  present  a  peculiar  phe- 
nomenon, varying  from  a  redness  or  a  pigmentation  of  the  skin  to 
deep  ulcers.  The  first  form  needs  no  special  treatment.  The  ulcers 
are  very  indolent,  and  may  require  from  one  to  two  years  to  heal  if 
left  to  themselves,  and  the  scars  are  liable  to  be  the  seat  of  carcinoma. 
The  best  form  of  treatment  for  severe  burns  seems  to  be  the  removal 
of  necrotic  tissue  and  granulations,  and  the  application  of  thick  grafts 
or  flaps  transferred  from  neighboring  healthy  tissue.  According  to  F. 
C.  Wood,  even  if  such  flap  grafts  slough,  they  sometimes  leave  the 
tissue  in  such  a  healthy  condition  that  Thiersch  grafts  will  then  grow 
satisfactorily. 


iSollman,  who  has  studied  this  method,  states  that  a  simple  paraffin  melting  at  or 
below  50°  C,  is  superior  or  equal  to  the  complex  mixtures  that  have  been  advocated. 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS.  79 

SUTURES. 

On  the  face  and  in  the  mouth,  interrupted  sutures  are  in  most  in- 
stances preferable  to  continuous  sutures.  And,  except  when  buried, 
silkworm  gut,  horsehair,  or  silver  wire  are  to  be  used  in  preference  to 
silk  or  catgut.  On  the  neck,  continuous  sutures  may  be  used  in  the 
form  of  the  ordinary  whip  stitch  or  the  glover's  stitch. 


Fig.    14. 


Pig.    15. 


Fig.    16. 


^hh- 


Fig.    17. 


^uTSRIN 


Fig.    18. 


Fig.    19. 


Fig.    20. 


Fig.   14.     Suture  that   causes   skin   edges   to   lap. 

Fig.  15.  A  suture  that  penetrates  too  deep  in  comparison  to  its  lateral  extent  may 
cause  a  depression  at  the  wound  edge. 

Fig.   16.      A  properly  placed  suture. 

Fig.   17.      Illustrating  how   each   suture   should   cross   the  wound   at    right   angles. 

Fig.  18.  A  deep  suture  suitable  for  a  mucous  surface  that  will  not  allow  the  mu- 
cous borders  to  overlap. 

Fig.  19.  A  modification  of  the  deep  stay  suture  that  Lane  uses  in  the  lip.  Tills 
Is  tied  on  the  mucous  surface. 

Fig.  20.  A  suture  that  approximates  the  deep  and  superficial  tissues.  This  suture 
must  be  drawn  loosely,  or  the  tissue  within  the  grasp  of  the  short  loop  of  the  suture  Is 
apt  to   slough. 

On  the  neck,  metal  clips  may  be  used  for  the  skin,  but  they  do  not 
approximate  the  platysma  muscle.  The  subcuticular  suture  of  silver 
wire,  silkworm  gut,  or  catgut,  when  accurately  done,  gives  a  nice  ap- 
proximation of  the  skin  and  of  the  adjacent  part  of  the  superficial 


80  SURGERY  OF  THE  MOUTH  AND  JAWS. 

fascia,  and  does  not  interfere  with  the  superficial  drainage  of  the  wound. 
Both  the  subcuticular  stitch  and  the  wound  clips  are  supposed  to  have 
the  advantage  of  avoiding  the  possibility  of  stitch  abscesses,  and  the 
former  of  leaving  no  stitch  scar.  We  believe,  however,  that  stitch 
abscesses  that  arise  purely  from  stitch  infection  are  the  result  of  pres- 
sure, as  are  the  stitch  scars ;  that  if  non-capillary  sutures  are  drawn 
only  sufficiently  tight  to  hold  the  tissues  in  contact,  and  are  removed 
in  from  one  to  three  days,  neither  stitch  abscesses  nor  scars  will 
result.  On  the  face  the  sutures  that  unite  the  skin  edges  should  not 
be  depended  on  to  overcome  tension.  Where  there  is  any  resistance 
to  the  approximation  of  the  flaps,  it  should  be  overcome  by  retention 
sutures. 

In  placing  interrupted  cutaneous  sutures,  there  should  be  a  relation 
between  the  depth  to  which  each  suture  penetrates  into  the  tissue  and 
its  width.  A  suture  that  embraces  a  large  skin  area  and  does  not 
penetrate  any  depth  into  the  tissue  may  cause  the  skin  margins  to  over- 
lap one  another  (Figs.  14  and  15).  It  is  not  necessary,  however,  that 
the  greatest  width  of  the  suture  should  be  on  the  skin  surface  (Fig. 
16).  Again,  there  should  be  a  proportion  between  the  width  and  depth 
of  the  suture  and  their  distaiice  from  each  other.  As  a  rule,  sutures 
should  penetrate  to  a  depth  equal  to  one  half  of  the  whole  of  its  width, 
and  they  should  not  be  placed  closer  together  than  is  necessary.  If  the 
tissues  are  held  in  place  by  a  stay  suture,  fewer  skin  sutures  will  be 
required.  If  gaping  occurs,  very  small  sutures,  including  only  the 
skin,  may  be  used  to  reinforce  when  necessary.  Each  suture  should 
cross  the  wound  at  right  angles  (Fig.  17).  (Several  plans  of  stay 
sutures  are  shown  in  Figs.  18  to  20.) 

Through-and-through  stay  sutures,  that  cross  the  skin  and  mucous 
surfaces,  cause  scars,  which,  though  they  may  ultimately  become  in- 
visible, certainly  detract  very  much  from  the  pleasure  of  an  immediate 
good  result. 

DRESSINGS. 

Dressings  are  applied  to  wounds  for  protection,  to  produce  pres- 
sure, to  absorb  secretions,  and  to  facilitate  drainage,  or  to  hold  some 
medicinal  agent  in  contact  with  the  part.  Dry,  well-approximated 
wounds  of  the  face  require  no  dressings.  The  slight  amount  of  secre- 
tion thfit  dries  at  the  edge  is  sufficient  protection,  while  dressings  ap- 
plied to  wounds  of  the  face  are  cumbersome  and  useless.  This  applies 
more  particularly  to  large  wounds  that  confine  the  patient  to  the  house. 
Approximated,  dry,  clean  wounds  may  be  covered  with  a  few  fibers 
of  cotton,  or  one  layer  of  gauze,  and  then  painted  with  thin  flexible 
collodion.  Adhesive  plaster  may  be  applied  to  hold  the  gauze  in  place, 
but  should  seldom  be  in  direct  contact  with  the  wound. 


WOUNDS,  INJURIES  OF  BONES  AND  SOFT  PARTS.  81 

Cutaneous  sutures  of  the  face  and  neck  should  be  removed  in  four 
days.  When  these  cutaneous  sutures  are  removed,  the  Hne  of  union 
is  protected  by  a  layer  of  gauze,  pasted  on  with  collodion.  When  it 
is  desired  to  remove  sutures  that  are  covered  with  collodion  and  gauze 
or  cotton,  the  latter  must  be  raised  with  care,  for  otherwise  the  wound 
may  be  torn  open.  On  clean  wounds  of  the  neck  and  under  surface 
of  the  chin,  dry  gauze,  covered  with  a  quantity  of  cotton,  is  applied, 
and  the  whole  is  bandaged  firmly  in  place. 

If  the  secretion  from  a  discharging-  wound  are  very  free,  dry 
gauze  may  be  applied ;  but  if  scanty,  the  gauze  should  be  moist,  to  en- 
courage drainage.  If  there  is  any  reason  why  the  gauze  should  be 
moist,  there  is  the  same  reason  why  it  should  remain  so,  and  moist 
gauze  should  be  completely  covered  with  rubber  tissue,  oil  silk,  rubber 
adhesive,  wax  paper,  or  some  other  impervious  covering. 

There  is  some  good  to  be  derived  from  applying  mild  antiseptic 
solutions  to  infected  granulating  surfaces.  The  application  we  com- 
monly use  is  a  wet  pack  with  saline  solution  (a  teaspoonful  of  salt  to 
a  pint  of  water),  frequently  changed,  which,  by  encouraging  drainage, 
not  allowing  the  dressing  to  stick  to  the  wound,  and  not  irritating  the 
granulations,  usually  accomplishes  all  that  is  to  be  desired.  If  an 
active  antiseptic  is  indicated,  we  use  either  50  per  cent  alcohol  or  5 
per  cent  solution  of  colloidal  silver.  A  50  per  cent  solution  of  alcohol 
applied  under  an  impervious  covering  will  irritate  the  skin.  Bichlorid 
of  mercury  is  not  active  in  the  presence  of  albumin,  and  carbolic  acid 
is  dangerous.^  With  the  possible  exception  of  alcohol  (50  to  75  per 
cent  solution),  we  know  of  no  advantage  that  is  to  be  derived  from 
incorporating  medicinal  agents  in  the  packs  applied  to  the  intact  skin. 
Moist  heat  applied  in  the  form  of  wet  packs  is  beneficial  to  inflam- 
matory conditions,  though  it  favors  suppuration. 

For  some  time  it  has  been  our  custom  to  expose  all  granulating 
surfaces  as  continuously  as  possible  for  hours  at  a  time  to  the  direct 
action  of  an  ordinary  electric  light,  and  believe  that  there  is  no  other 
treatment  that  we  have  seen  that  will  cause  such  rapid  cleaning  of 
dirty  surfaces  and  contraction  of  granulations.  Sometimes  wounds 
are  held  open  by  self-retaining  retractors  so  that  the  light  can  pene- 
trate from  a  standard  lamp ;  in  other  cases  a  small  automobile  tail- 
lamp  run  by  a  storage  battery  is  let  down  into  the  wound  and  held 
about  15  cm.  from  the  granulations. 

When  granulations  are  inclined  to  become  covered  with  a  dry  scab 
that  does  not  confine  wound  secretions,  the  process  may  be  encouraged 


2It  is  in  this  field  that  the  Carrel-Dakiu  treatment  has  made  such  a  name,  but  since 
this  method  is  still  undergoing  modification,  and  since  its  technique  has  been  so  thor- 
oughly set  forth  in  the  literature  and  in  special  army  schools,  a  description  here  would 
be  out  of  place. 


82  SURGERY  OF  THE  MOUTH  AND  JAWS. 

by  an  antiseptic  dusting  powder.  The  one  we  ordinarily  use  is  the 
subiodid  of  bismuth. 

Skin  that  is  irritated  by  a  wound  discharge  should  be  protected 
with  an  unguent.  The  ordinary  unguentum  zinci  oxidi  is  as  efficacious 
as  any,  and  there  is  no  reason  why  it  should  not  be  sterile. 

A  5  per  cent  xeroform  ointment  is  an  efficient  application  for 
superficial  skin  infections  due  to  contact  with  wound  secretions. 


CHAPTER  VI. 
INJURIES  OF  THE  TEETH  AND  ALVEOLAR  PROCESS. 

Mechanical  injuries  of  the  teeth  may  result  from  abrasion,  tension, 
or  violence.  The  resulting  condition  and  treatment  will  depend  on 
the  nature  and  extent  of  the  injury. 

MECHANICAL  ABRASION  OF  THE  TEETH. 

Mechanical  abrasion  of  the  occlusal  surfaces  of  the  teeth  is  usually 
present  after  middle  age,  and  increases  with  advancing  age.  The 
character  of  the  food,  mechanical  impurities  in  the  atmosphere,  and  the 
low  resistance  of  the  tooth  substance  are  the  principal  agents  involved 
in  the  process  of  mechanical  abrasion.  The  wearing  away  of  the  tooth 
structure  occurs  most  frequently  in  persons  who  are  persistent  tobacco 
or  betel  nut  chewers,  those  who  subsist  on  coarse,  tough  foodstuffs, 
and  those  who  live  in  an  atmosphere  containing  sand  or  grit.  Work- 
ers in  glass  factories  using  sand  blasts  and  the  Bedouins  of  the  desert 
show  a  marked  degree  of  mechanical  abrasion  of  the  teeth.  Pro- 
nounced cases  of  mechanical  abrasion  by  any  of  the  above  named 
causes  are  usually  found  only  in  persons  who  have  passed  middle  life. 
In  some  cases  the  crowns  of  the  teeth  may  be  worn  away  to  the  gums. 

Symptoms. — When  the  tooth  substance  is  slowly  worn  off,  a 
chronic  mechanical  stimulation  of  the  dentin-forming  elements  of  the 
pulp  results,  which  manifests  itself  in  the  production  of  secondary 
dentin.  This  new  dentin  is  deposited  in  irregular  masses  in  the  pulp 
chamber,  causing  a  slow  progressive  atrophy  of  this  organ,  which,  in 
pronounced  cases,  may  result  in  the  total  obliteration  of  the  pulp  canal. 
Mechanical  abrasion  rarely  causes  hypersensitiveness  of  the  dentin  or 
exposure  of  the  pulp. 

Treatment. — The  proper  treatment  for  mechanical  abrasion  con- 
sists in  the  restoration  of  the  lost  tooth  substance  by  means  of  proper 
filling  or  capping  of  the  abraded  surfaces  until  useful  occlusion  is  ob- 
tained. Should  the  dentin  become  hypersensitive,  or  the  pulp  exposed, 
devitalization  of  the  latter  and  its  replacement  by  some  inert  perma- 
nent material  are  the  usual  surgical  procedures.  Medicinal  applica- 
tions for  the  alleviation  of  pain  resulting  from  this  wearing  away  serve 
their  purpose  only  temporarily. 

83 


84  SURGERY  OF  THE  MOUTH  AND  JAWS. 

LOOSENING  OR  AVULSION  OF  THE  TEETH. 

In  the  process  of  separating  the  teeth,  or  in  orthodontic  procedures, 
too  much  strain  may  be  brought  on  a  tooth,  and  as  a  consequence,  its 
pulp  may  die.  As  a  result  of  violence,  a  tooth  may  become  loosened 
in  its  socket  or  entirely  avulsed. 

Treatment. — A  tooth  which  is  simply  loosened  without  fracture 
of  the  aveolar  process  will  usually  regain  its  normal  solidity  without 
treatment.  A  tooth  that  has  been  forced  from  its  normal  position,  but 
which  has  not  entirely  left  its  aveolar  socket,  is  called  a  displaced  tooth. 
It  should  be  replaced  in  its  normal  position,  and  held  there  by  silk  or 
wire  ligatures,  or  metal  bands,  attached  to  the  neighboring  teeth,  until 
it  has  become  solid. 

A  tooth  that  has  left  its  socket  may  sometimes  be  replaced.  Before 
replantation,  the  tooth  is  opened  by  cutting  off  about  one-eighth  inch 
of  its  root.  The  root  canal  is  cleaned,  sterilized,  and  filled,  and  the 
tooth  is  washed  in  normal  saline  solution.  It  is  now  forced  into  the 
thoroughly  cleaned  socket,  and  held  in  place  by  a  ligature  or  a  metal 
splint  until  it  has  again  become  solid.  The  tooth  should  be  replaced 
as  soon  as  possible  after  the  accident  occurs,  although  there  are  many 
cases  on  record  in  which  replantation  was  performed  days  and  even 
weeks  after  the  separation  from  its  socket.  In  a  multirooted  tooth  a 
broken-off  root  may  be  replaced  by  a  porcelain  root  according  to  a 
method  devised  by  Rhein. 

A  transplanted  tooth  is  one  which  is  inserted  into  a  natural  alveolus 
other  than  the  one  from  which  it  originated.  The  preparation  of  the 
tooth  and  its  replacement  and  retention  are  the  same  as  outlined  for  a 
replanted  tooth. 

An  implanted  tooth  is  one  which  is  inserted  into  an  artificial  socket 
made  into  the  alveolar  bone  with  special  reamers,  trephines,  etc.  The 
mode  of  procedure  of  preparing  the  tooth,  etc.,  is  the  same  as  outlined 
for  replantation. 

In  replantation  and  transplantation  of  a  tooth  which  is  freshly  re- 
moved from  its  socket,  as  much  as  possible  of  the  periosteum  of  the 
alveolus  and  of  the  pericementum  of  the  tooth  should  be  preserved. 
Such  teeth  must  not  be  boiled  before  replantation,  but  they  should  be 
preserved  in  physiologic  salt  solution  at  body  temperature.  The 
alveolus  is  washed  with  the  warm  saline  solution,  or  a  5  per  cent  col- 
loidal silver  solution,  but  no  irritating  antiseptics  should  be  used.  After 
the  operation  the  mouth  must  be  kept  clean  with  an  efficient  mouth 
wash.  The  replaced  tooth  is  in  a  majority  of  cases  mechanically  re- 
tained by  the  growth  of  connective  tissue  fibers,  which  encircle  the 
tooth  firmly,  and  it  usually  remains  in  place  from  four  to  seven  years. 


INJURIES  TO  THE  TEETH  AND  ALVEOLAR  PROCESS.         85 

'     FRACTURE  OF  THE  TEETH. 

As  a  result  of  violence,  a  tooth  may  suffer  injury,  varying  from 
slight  chipping  of  the  enamel  to  a  fracture  of  the  body  of  the  crown, 
or  of  the  root.  Decay  may  so  weaken  a  crown,  without  necessarily 
destroying  all  of  its  enamel,  that  it  may  readily  fracture  on  very  slight 
pressure.  Nature  has  not,  except  by  the  deposition  of  secondary  den- 
tin, made  provisions  for  repair  of  the  teeth,  and  therefore  lost  tooth 
structure  must  be  replaced  mechanically  by  the  dentist  if  the  normal 
outline  of  the  teeth  is  to  be  restored. 

Treatment. — If  the  crown  of  a  tooth  is  fractured,  it  may  be  re- 
placed with  an  artificial  substitute ;  if  the  root  is  fractured,  an  attempt 
may  be  made  in  some  cases  to  save  it  by  banding.  Callous  union  may 
occur  if  the  pulp  recovers. 

FRACTURE  OF  THE  ALVEOLAR  PROCESS. 

Fractures  of  the  alveolar  process  that  are  not  associated  with  frac- 
ture of  the  body  of  the  jaw  are  usually  secondary  to  the  displacement 
or  extraction  of  one  or  several  teeth.  The  fracture  may  involve  a 
large  section  of  the  process  and  carry  with  it  several  teeth,  or  it  may 
be  splintered  in  the  neighborhood  of  one  tooth. 

Treatment. — All  fragments  of  the  alveolus  attached  to  the  soft 
tissues  should  be  replaced.  If  there  are  teeth  in  the  fragment,  these 
should  be  fixed  to  neighboring  solid  teeth.  All  detached  fragments 
should  be  removed,  as  they  will  be  ultimately  thrown  off,  and  until 
removed,  are  a  source  of  irritation. 


CHAPTER  VII. 

FRACTURES  OF  THE  UPPER  JAW. 

As  has  been  pointed  out  by  Cryer,  the  maxillary  bones  include,  sur- 
gically, the  malar,  the  palate,  the  inferior  turbinate,  the  lacrymal,  the 
nasal,  and  the  lateral  masses  of  the  ethmoid  and  the  nasal  septum,  as 
any  or  all  of  them  are  liable  to  be  involved  in  injuries  characterized  as 
fractures  of  the  maxillary  bones. 

The  nasal  bones,  with  or  without  involvement  of  the  septum,  are 
more  often  fractured  than  any  of  the  others,  and  most  commonly  with- 
out injury  of  the  other  bones.  Either  of  the  malar  bones,  with  their 
zygomatic  processes,  may  be  fractured  or  displaced  without  extensive' 
injury  to  neighboring  bone  structures. 

CHARACTER  OF  THE  INJURY. 

Fractures  of  the  maxillary  bones  may  vary  in  extent  from  injuries 
to  the  alveolar  process  to  a  tearing  loose  of  all  of  the  facial  bones  by 
a  transverse  fracture  at  or  near  their  attachment  to  the  cranium,  the 
latter  being  often  associated  with  extensive  fractures  of  the  brain  case 
and  brain  injury.  The  prominence  of  the  cheek  bone  usually  receives 
the  force  that  causes  such  extensive  injuries,  and  it  is  not  uncommon 
to  find  that  the  malar  bone  and  the  body  of  the  maxilla  of  that  side  are 
crushed. 

In  the  present  war  all  varieties  of  gunshot  and  shell  injuries  have 
been  encountered  from  more  or  less  clean  through-and-through  shots  to 
tearing  out  of  great  masses  of  bone  and  flesh.  These  gunshot 
injuries  are  considered   with  gunshot   injuries  of   the  lower  jaw. 

Displacement. — The  displacement  is  always  due  to  the  original 
violence  or  to  gravity.  The  hard  palate  may  be  pushed  upward  until 
it  infringes  on  the  nasal  fossa,  and  displacement  of  the  alveolar 
process  will  vary  with  the  direction  of  the  force.  Extensive  fractures 
of  the  maxillae,  involving  other  facial  bones,  without  loss  of  sub- 
stance, may  be  divided  into  two  classes  according  to  the  character 
of  the  predominant  displacement:  (1)  if  a  severe  force  is  applied 
from  in  front  in  an  upward  and  backward  direction,  such  as  the 
kick  of  a  horse,  the  maxillse  may  be  driven  in  toward  the  base  of 
the  cranium  with  considerable  comminution  and  impaction;  or  (2), 
if,  as  is  most  commonly  the  case,  the  force  is  applied  to  the  promi- 
nence of  the  cheek,  the  malar  bone  will  be  more  or  less  driven  into 

86 


FRACTURES  OF  THE  UPPER  JAW.  87 

the  maxillary  'antrum,  but  at  the  same  time  there  may  be  extensive 
radiating  fractures.  If  one  of  these  is  a  transverse  fracture  through 
the  orbits,  the  whole  bony  framework  of  the  face  may  sag  down, 
supported  only  by  the  soft  tissues. 

In  certain  shell  injuries  the  soft  tissues  may  be  so  extensively 
cut  as  to  render  but  a  partial  support.  It  is  with  the  transverse 
facial  fractures  that  basal  fractures  are  most  liable  to  occur.  In 
some  instances,  by  taking  hold  of  the  upper  teeth,  the  whole  face 
can  be  made  to  move  on  the  cranium,  and  we  have  seen  the  skin 
at  the  root  of  the  nose  puff  out  and  in  with  each  respiration,  while 
the  pulsations  of  the  brain  were  plainly  visible,  transmitted  to  the 
skin  through  crevices  in  the  vault. 

Diagnosis. — There  can  be  no  difficulty  in  diagnosing  fractures 
with  displacement  which  extend  into  the  alveolar  process.  Slight  de- 
pressions or  displacement  of  the  malar  bones  might  be  overlooked  on 
casual  inspection,  and  if  there  is  much  swelling,  it  may  be  impossible 
to  detect  the  displacement  by  palpation.  In  all  cases  of  injury  of  the 
face  the  dental  arches  and  the  palate  should  be  inspected,  and  the  facial 
bones  outlined  digitally.  This  is  best  done  by  standing  behind  the  pa- 
tient, and  with  the  thumb  and  fingers  of  both  hands  examining  simul- 
taneously the  orbital  borders  and  the  intraoral  and  extraoral  outlines  of 
the  malar,  maxillary,  and  nasar  bones,  and  of  the  zygomatic  arches. 
A  definite  local  tenderness  that  can  be  elicited  by  pressure  made  on  a 
distant  point  or  points,  the  force  being  transmitted  through  the  bone, 
is  always  suggestive  of  a  fracture  at  the  tender  point.  Slight  lateral 
deviation  of  the  nasal  bones  may  be  detected  by  making  a  pencil  mark 
in  the  center  of  the  bony  ridge,  and  then  viewing  it  from  above  while 
standing  behind  the  patient.  The  swelling  that  obscures  the  diagnosis 
may  be  modified  by  cold  applications  or  by  digital  pressure  under  an 
anesthetic,  where  available,  an  x-ray  negative  may  in  some  cases 
settle  the  question. 

TREATMENT. 

As  with  fracture  of  the  mandible,  treatment  consists  both  in  the 
care  of  the  tissues  and  in  the  mechanical  treatment  of  the  fracture. 
These  fractures  are  often  accompanied  by  very  severe  shock,  and  may 
be  but  part  of  an  injury  that  involves  concussion  or  laceration  of 
the  brain  or  intracranial  hemorrhage.  Emphysema  of  the  cellular  tis- 
sue of  the  face  is  not  an  uncommon  complication  of  fractures  involving 
the  nasal  fossa  or  maxillary  antrum.  The:"e  may  be  considerable  swell- 
ing, and  if  the  patient  is  not  seen  until  some  hours  after  the  injury  has 
occurred,  this  can  obscure  the  exact  nature  of  the  fracture  and  of  itself 
cause  obstruction  of  the  nasal  passages. 


88  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Even  in  simple  fracture  any  of  the  structures  contained  in 
the  face  may  be  injured — more  particularly  the  maxillary  division 
of  the  fifth  nerve,  the  branches  of  the  internal  maxillary  artery,  and 
the  lacrymal  duct.  Sepsis  may  follow,  as  these  fractures,  extending 
into  the  antrum  or  nasal  fossa,  are  usually  open. 

In  gunshot  or  shell  injuries  any  amount  of  tissue  may  be  torn 
away  or  a  sharp  fragment  may  cut  deeply,  leaving  a  part  of  the 
face  sagging  with  a  wide  exposure  of  the  deeper  structure  cavi- 
ties. 

In  caring  for  a  simple  fracture  itself,  the  surgeon  usually  does 
all  that  is  necessary  when  he  restores  and  retains  the  bones  in  their 
proper  relations  and  keeps  the  involved  cavities  as  free  as  possible 
from  material  that  would  promote  sepsis. 

In  the  more  extensive  open  fractures,  and  in  cases  of  great  loss 
of  tissue,  not  only  must  the  remaining  bones  be  placed  as  nearly 
as  possible  in  their  normal  position,  but  the  treatment  of  the  open 
wound  must  be  instituted. 

Care  of  the  Tissues. — Often  the  care  of  the  patient  is  of  greater 
importance.  Emphysema  is  best  combated  by  insuring  free  egress  of 
air  through  the  nose  or  mouth.  In  rapidly  extending  emphysema  we 
have  plugged  the  posterior  nares,  and  the  effect  was  beneficial.  Cold, 
in  the  form  of  an  ice  bag,  is  the  most  efficient  means  of  preventing 
or  treating  the  swelling  due  to  the  infiltration  of  the  tissues  with  serum. 
The  cold  should  be  so  applied  as  to  cool,  but  not  freeze,  the  tissues. 
If,  owing  to  swelling,  breathing  is  labored,  it  can  be  partially  relieved 
by  dropping  a  solution  of  adrenalin  chlorid  into  the  nostrils.  Until 
proper  fixation  is  applied,  breathing  can  sometimes  be  facilitated  by 
placing  in  the  mouth  a  large  rubber  tube  that  extends  back  to  the  oral 
pharynx.  Injury  to  the  maxillary  nerve  may  be  evidenced  by  an  an- 
esthesia over  the  area  of  distribution,  or  later  by  a  neuralgia,  but  it  is 
not  common.  Hemorrhage,  though  it  may  be  sharp  at  first,  is  in  simple 
fractures  usually  self-limited.  Obstruction  of  the  nasal  duct  that 
is  not  relieved  with  the  subsidence  of  the  swelling  would  need  special 
attention  later. 

Sepsis  is  to  be  combated  by  frequent  irrigation  of  the  nasal  and 
oral  cavities,  and  if  the  maxillary  antrum  is  widely  open,  this  should 
receive  the  same  treatment.  If  the  antrum  contains  an  infected  blood 
clot,  it  should  be  opened  and  cleansed.  In  douching  the  nasal  cavity, 
the  patient  should,  if  possible,  be  in  a  sitting  or  semierect  position, 
and  no  forceful  stream  should  be  used.  If  the  lower  portion  of  the 
nasal  fossa  is  kept  clear,  the  discharge  from  its  upper  part  will  flow 
down  and  not  collect.  It  should  be  remembered  that  when  fluids  are 
forced  to  the  upper  part  of  the  nasal  fossa  there  is  danger  of  infection 


FRACTURES  OF  THE  UPPER  JAW. 


89 


of  the  accessc5ry  sinuses.  In  these  simple  fractures  the  most  serious 
compHcation  is  a  fracture  of  the  base  of  the  cranium,  which,  besides 
being  often  accompanied  by  brain  injury  that  may  be  of  itself  fatal, 
leaves  an  open  avenue  to  intracranial  infection.  In  all  severe  cases, 
hexamythylene  tetramine  may  be  administered  in  fairly  large  doses 
in  an  attempt  to  render  the  mucus  and  the  cerebrospinal  fluid  anti- 
septic. Under  no  circumstances  should  any  considerable  quantity 
of  attached  bone  be  removed.  The  bones  connected  with  the  maxilla 
are  well  nourished,  and,  unless  absolutely  detached,  will  usually 
unite  if  replaced,  while  the  loss  of  even  small  pieces  will  leave 
noticeable  deformity.  This  holds  true  particularly  in  cases  where 
the  whole  face  is  crumpled  up  by  some  severe  blow  in  front,  such 
as  the  kick  of  a  horse  or  the  passage  of  a  shell  fragment. 

Mechanical  Treatment  of  the  Fracture. — For  treatment  of  frac- 
tures of  the  alveolar  process  see  Injuries  of  the  Teeth  and  Alveolar 
Process,  page  85. 


Fig.  21.  Showing  a  method  of  supporting  one  maxilla,  after  fracture  through  the 
body,  by  wiring  the  lower  to  the  upper  jaw  on  the  sound  side. 

Injury  to  the  palatal  process  is  rare,  and  is  due  as  a  rule  to  a 
gunshot  wound  that  will  not  need  mechanical  fixation. 

Impactions  must  be  carefully  diagnosed,  and  the  bones  restored  to 
their  normal  outline.  For  this  purpose  the  antrum  may  be  opened 
from  the  mouth  above  the  canine  fossa,  and  the  bones  pried  outward 
or  downward  with  a  steel  urethral  sound.  The  malar  bones,  the 
zygomatic  process,  and  the  lower  border  of  the  orbit  can  be  manipu- 
lated into  place  with  least  disfigurement  by  inserting  a  strong,  sharp, 
steel  hook  through  the  tissues  to  engage  on  the  various  edges  of  the 
bones.  If  the  impaction  cannot  be  broken  up  in  this  way,  resort  may 
be  had  to  a  small,  sharp  chisel.  Unless  the  bones  are  terribly  shat- 
tered, there  is  little  tendency  for  the  deformity  to  recur.  If  there  is 
this  tendency,  the  bones  can  be  wired  in  appropriate  places  (Fig.  21). 


90  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Transverse  facial  fractures,  with  a  downward  sagging  of  the  max- 
illae, are  best  treated  by  supporting  the  facial  bones  by  pressure  exerted 
upward  on  the  upper  teeth  or  alveolar  processes.  It  is  often  not  prac- 
tical to  do  this  by  bandaging  the  lower  jaw  against  the  upper,  be- 
cause the  support  is  inadequate,  and  because  in  such  cases  the  nasal 
fossae  are  almost  invariably  obstructed  by  swelling  and  the  patient 
must  breathe  through  the  mouth.  (See  emergency  treatment  of  frac- 
tures.) Goffres  and  Graefe  have  both  devised  methods  that  consist 
essentially  of  adjustable  steel  bars  that  pass  from  a  head  band  and 
enter  the  mouth,  and  hook  on  to  the  upper  dental  arch.  We  believe 
the  more  .practical  and  efficient  method  of  supporting  the  maxillary 
and  facial  bones  under  these  circumstances  is  to  wire  them  in  their 
appropriate  places,  or  better  to  use  a  Kingsley  splint  reversed,  after 
the  method  suggested  by  Dr.  John  S.  Marshall.  It  consists  in  apply- 
ing a  Kingsley  splint  to  the  upper  jaw  and  supporting  it  from  above 
with  a  head  bandage,  or  preferably  a  celluloid  cap  or  a  cap  made 
of  padded  metal  bands.  "Impressions  of  the  upper  and  lower  teeth 
were  taken  with  the  modeling  compound  by  first  molding  it  upon 
the  upper  teeth  and  while  it  was  yet  soft  forcing  the  lower  jaw 
upward  until  a  correct  occlusion  of  the  teeth  was  obtained.  This 
impression  was  trimmed  to  the  desired  shape ;  a  one-eighth-inch  steel 
wire  was  imbedded  in  the  sides  on  a  line  with  the  ends  of  the 
teeth,  then  bent  backward  upon  itself  opposite  the  cuspid  teeth,  and 
allowed  to  extend  outside  the  cheek  nearly  to  the  lower  border  of 
the  ear.  From  this  was  constructed  a  hard-rubber  splint,  with  the 
wires  attached.  This  splint  can  be  made  from  silver  swaged  over 
metal  dies,  but  if  a  metal  plate  is  desired,  the  most  perfect  adaption 
can  be  secured  by  the  electro-deposit  plate,  the  wires  being  attached 
with  solder.  The  splint  is  held  in  position  by  means  of  double 
elastic  straps  attached  to  the  wire  on  each  side  and  buckled  to  a  close- 
fitting  leather  or  net  cap,  which  is  reinforced  with  leather  and  laced 
firmly  on  the  head.  This  proved  to  be  a  very  successful  appliance, 
as  it  held  the  fractured  bones  in  their  proper  position  and  permitted 
comfortable  breathing  and  free  movement  of  the  lower  jaw,  which 
enabled  him  to  talk,  and,  after  a  few  days,  masticate  soft  food. 
Deep  indentations  were  made  in  the  under  side  of  the  splint,  in 
which  the  lower  teeth  fitted  accurately  when  the  mouth  was  closed. 
The  object  of  this  was  to  furnish  a  sure  guide  to  the  normal  posi- 
tion of  the  superior  maxillae.  Without  this  the  correctness  of  the 
adjustment  of  the  bones  could  not  have  been  verified.  Its  importance 
tberefore  cannot  be  overestimated." 

If,  at  the  time  of  taking  the  impression,  the  fragments  of  the  upper 
alveolar  process  are  not  in  perfect  alignment,  a  reconstruction  can  be 


FRACTURES  OF  THE  UPPER  JAW. 


91 


made,  and  the  splint  is  made  over  this  restored  arch.  If  the  patient 
has  an  upper  plate  that  has  escaped  injury,  it  may  be  converted  into 
a  splint  by  attaching  arms.     (Fig.  22  shows  the  spHnt  in  use.) 

This  splint  is  to  be  retained  until  the  bones  have  attained  sufficient 
anchorage  to  hold  them  in  position.  If  there  is  much  loss  of  bone  on 
either  side  of  the  nose  in  front,  the  lower  part  of  the  maxillae  ma)- 
have  only  a  fibrous  attachment  or  may  be  drawn  upward.  To  correct 
this  and  at  the  same  time  restore  the  bridge  of  the  nose,  we  have 
transferred  an  osteoplastic  flap,  including  part  of  the  anterior  wall 
of  the  frontal  sinuses.  This  makes  a  bridge  between  the  frontal  bone 
and  the  maxillae. 


Fig.  22.  Marshall's  method  of  supporting  the  maxillfe,  in  transverse  fracture  of 
the  face,  with  a  Kingsley  splint.  The  arms  of  the  splint,  which  are  detachable,  protrude 
from  the  mouth  at  each  corner  and  lie  close  to  the  side  of  each  cheek. 

In  the  mechanical  treatment  of  a  case  with  much  loss  or  com- 
minution of  bone  between  the  palate  and  the  base  of  the  skull  then 
the  Marshall  modification  of  the  Kingsley  splint  is  not  applicable,  for 
the  upward  pull  of  the  bands  will  tend  to  displace  the  palate  and 
alveolar  parts  upward.  In  such  cases  the  upper  alveolar  arch  is 
either  to  be  fixed  to  the  lower  by  intermaxillary  wiring  of  the  teeth 
or  a  swaged  metal  splint  is  cemented  to  the  upper  teeth  and  attached 
to  a  fixed  head  cap  by  metal  rods  that  will  hold  the  dental  arch 
in  its  proper  relation  to  the  lower  and  maintain  its  proper  distance 
from  the  base  of  the  skull.     Later,  if  necessary,  a  bone  graft  bridge 


92 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Fig.  23.      Swaged  metal  splint  with  rigid  bars  attached  to  head  cap,  for  comminuted 
fracture   of   the   upper   jaw. — After   Ombredanne. 


may  be  implanted  to  give  stability  to  the  maxillary  arch.  Various 
external  pressure  pads  may  be  fixed  by  rods  to  the  jaw  splint.  (Fig. 
23.) 


CHAPTER  VIII. 

FRACTURES  OF  THE  LOWER  JAW. 

Owing  to  its  position,  the  lower  jaw  acts  somewhat  as  a  guard  to 
the  rest  of  the  face.  It  is  more  exposed  to  violence  and  is  more  often 
fractured  than  any  other  of  the  face  bones.  Owing  to  its  loose  con- 
nection with  the  skull,  fractures  of  the  lower  jaw  are  much  less  likely 
to  be  complicated  by  skull  or  brain  injury  than  a  fracture  of  the  upper 
jaw.  It  is  a  fracture  that  frequently  occurs  in  fist  fights,  and  nat- 
urally alcoholism  is  often  a  predisposing  factor.  It  is  much  more  fre- 
quent in  men  than  in  women.  In  war  surgery  it  is  comparatively 
common  and  is  a  frequent  complication  of  more  extensive  injuries. 

CHARACTER  OF  THE  INJURY. 

The  mandible  may  be  broken  by  direct  or  indirect  violence  in  any 
part.  Because  of  the  tooth  sockets,  and  its  more  exposed  position, 
fractures  of  the  body  are  more  common  than  those  of  the  ramus  and 
its  processes,  the  latter  constituting  less  than  5  per  cent  of  the  breaks. 
The  former  are  more  frequently  caused  by  direct,  the  latter  by  indirect, 
violence.  The  bone  is  very  hard  and  brittle,  and  splintering  at  the  site 
of  fractures  is  not  uncommon,  especially  with  gunshot  injuries,  which 
latter  will  be  considered  in  a  separate  section.  Fractures  of  the  body 
usually  communicate  with  the  mouth  cavity. 

Displacement. — While  the  displacement  of  the  fragments  of  the 
fractured  lower  jaw  may  have  been  primarily  produced  by  violence, 
it  is  always  maintained  or  modified  by  the  action  of  the  muscles  to 
which  the  jaw  gives  attachment.  In  treating  fractures  of  this  bone, 
it  is  not  of  so  much  importance  to  be  acquainted  with  the  large  assort- 
ment of  the  various  forms  of  apparatus  that  have  been  devised  for  this 
purpose,  as  to  understand  the  muscular  actions  that  caused  displace- 
ment. With  this  knowledge,  a  relatively  simple  armamentarium  will 
be  sufficient  to  get  nice  results  in  nearly  all  cases. 

The  lower  jaw  is  a  bar  of  bone,  bent  at  the  chin  and  at  the  angles, 
and  somewhat  loosely  attached  to  the  base  of  the  skull  at  the  condyles. 
The  axis  of  motion  in  the  simple  action  of  opening  and  closing  the 
mouth  is  not  at  the  condyles,  but  near  the  upper  openings  of  the  in- 
ferior dental  canals,  which  are  situated  in  the  middle  of  the  ramus 
at  the  level  of  the  occlusal  plane  and  molars.  On  the  intact  jaw,  the 
actions  of  its  various  muscles  are  nicely  balanced ;  but  when  a  fracture 

93 


94 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


occurs,  the  action  of  certain  groups  is  no  longer  opposed,  and  displace- 
ment is  produced  and  maintained. 

In  the  diagrammatic  schemes  here  illustrated,  no  attempt  is  made 
to  include  the  finer  actions  of  the  muscles,  but  only  those  which  are 
responsible  for  the  gross  displacements  that  ordinarily  occur.  The 
displacement  will  depend  upon  the  direction  and  position  of  the  frac- 
tures or  fracture ;  the  amount  of  displacement  in  any  one  place  will 
depend  upon  the  amount  of  laceration  of  soft  tissues  covering  the  bone, 


Pig.    26. 


F'g.    27. 


Pig.  24.  The  arrows  show  the  direction  of  horizontal  traction  of  the  mylohyoid, 
geniohyoid,  genlohyoglossi,  and  digastric  muscles  on  the  jaw.  The  light  arrows  repre- 
sent the  fibers  of  the  mylohyoid  muscles,  and  the  two  heavy  arrows  represent  the  genio- 
hyoid, genlohyoglossi,  and  digastric  muscles. 

Fig.  25.  Diagram  showing  possible  horizontal  displacement  in  a  fracture  in  the 
bicuspid  or  molar  regions. 

Fig.  26.  Diagram  showing  possible  horizontal  displacement  in  a  double  fracture  in 
the  mental  portion  of  the  body. 

Fig.  27.  Diagram  showing  possible  horizontal  displacement  in  a  fracture  of  the 
body  near  the   angle. 


and  the  direction  of  the  fracture.  It  will  simplify  the  presentation  of 
the  subject  to  consider  the  displacement  that  may  occur  in  the  hori- 
zontal and  in  the  vertical  planes  separately,  and  leave  the  reader  to 
draw  conclusions  as  to  what  will  be  the  actual  displacement  in  any 
particular  instance. 


FRACTURES  OF  THE  LOWER  JAW. 


95 


The  mylohyoid  muscle,  which  forms  the  floor  of  the  mouth,  extends 
from  the  concavity  of  the  body  of  the  mandible  to  the  body  of  the 
hyoid  bone,  and  the  direction  of  its  pull  is  represented  by  the  finer  ar- 
rows in  Fig.  24.  The  geniohyoglossi,  digastric,  and  geniohyoid  mus- 
cles together  make  a  strong  muscular  mass  that  extends  from  the  back 
of  the  symphysis  to  the  body  of  the  hyoid,  and  their  combined  pull 
is  represented  by  the  two  heavy  arrows  in  Fig.  24.  In  a  vertical  frac- 
ture at  the  symphysis,  the  muscular  balance  will  not  be  disturbed,  and 
there  will  be  no  horizontal  displacement.     In  a  fracture  or  fractures 


Fig.    29. 


Pig.    31. 


Fig.  28.  Showing  the  direction  of  traction  of  the  geniohyoid,  geniohyoglossi,  digas- 
tric, and  mylohyoid  muscles. 

Fig.  29.  Diagram  of  a  fracture  in  front  of  the  cuspid  showing  characteristic  dis- 
placement. 

Fig.  30.  Diagram  showing  possible  vertical  displacement  in  a  double  fracture  of 
the  mental  portion  of  the  body. 

Pig.  31.  Diagram  showing  an  instance  in  which,  owing  to  the  directions  of  the 
planes  of  fracture,  there  could  be  no  vertical  displacement. 

of  the  body  at  any  place  between  the  symphysis  and  angle,  granting 
that  the  mucoperiosteum  is  torn,  and  unless  prevented  by  the  direction 
of  the  lines  of  the  fracture,  the  displacement  will  be  as  shown  in  Fig. 
25.  The  portion  of  the  mylohyoid  attached  to  the  smaller  fragment 
will  draw  the  latter  toward  the  median  line.  The  whole  of  the  mylo- 
hyoid of  the  opposite  side  together  with  the  muscles  attached  to  the 


96  SURGERY  OF  THE  MOUTH  AND  JAWS. 

symphysis  will  draw  the  mental  portion  of  the  larger  fragment  back- 
ward and  to  the  side  of  the  fracture.  If  there  is  a  fracture  on  both 
sides,  then  the  mental  fragment  might  be  pulled  backward  (Fig.  26), 
but  as  can  be  readily  understood,  the  direction  of  the  line  of  fracture 
may  be  such  as  to  prevent  this  displacement.  In  fractures  near  the 
angle,  the  body  may  be  drawn  backward  on  the  fractured  side  (Fig. 
27). 

The  hyoid  bone  is  situated  on  a  lower  plane  than  the  attachment 
of  the  muscles  to  the  inner  surface  of  the  body  of  the  mandible,  and 
therefore  they  all  draw  the  bone  downward  as  well  as  backward,  most 
of  the  force  being  expended  on  the  mental  portion  (Fig.  28).  As 
long  as  the  body  of  the  bone  is  intact,  until  the  temporals,  masseters, 
and  internal  pterygoids  voluntarily  relax,  these  more  powerful  muscles 
neutralize  the  downward  pull  of  the  muscles  attached  to  the  hyoid 
bone.  If,  however,  a  break  occurs  at  any  place  between  the  angle  and 
the  symphysis,  unless  prevented  by  the  direction  of  the  line  of  fracture, 


Fig.  32.  Diagram  indicating  by  arrows  the  direction  of  traction  on  the  jaw  of  the 
various  groups  of  attached  muscles.  T,  temporal  muscle  ;  M,  masseter  and  internal 
pterygoid  muscles ;  ET,  external  pterygoid  muscle  ;  H,  muscles  attached  to  the  hyoid 
bone  ;  X,  axis  of  motion  in  opening  the  mouth. 

the  mental  fragment  will  be  pulled  downward  as  well  as  backward. 
If  the  fracture  is  single,  there  will  be  but  a  downward  tilting  of  the 
mental  fragment,  greatest  at  the  site  of  fracture  (Fig.  29).  If  there 
is  a  fracture  on  each  side  of  the  symphysis,  the  mental  fragment  may 
be  pulled  bodily  downward  as  well  as  backward  (Fig.  30),  but  in  the 
case  of  either  the  single  or  double  fracture,  the  line  of  fracture  may  be 
such  as  to  preclude  displacement  (Fig.  31). 

In  any  fracture  of  the  body,  whether  single  or  multiple,  there  is  apt 
to  be  a  combined  vertical  and  horizontal  displacement,  but  its  occur- 
rence will  be  governed  by  the  principles  just  illustrated.  In  a  double 
fracture  of  the  anterior  part  of  the  body,  the  backward  dislocation  of 


FRACTURES  OF  THE  LOWER  JAW.  97 

the  mental  fragment  might  allow  the  tongue  to  fall  back  on  the  glottis 
and  cause  dyspnea. 

The  muscles  of  mastication  are  attached  to  the  ramus  of  the  jaw 
and  its  processes.  Of  these,  the  masseter,  the  temporal,  and  the  in- 
ternal pterygoid  are  concerned  in  closing  the  mouth,  while  the  external 
pterygoid  assists  the  mandibulohyoid  muscles  in  opening  the  mouth. 
The  direction  of  the  pull  of  these  various  muscles  is  illustrated  in  Fig. 
32.  The  internal  pterygoid  muscle  passes  downward,  backward,  and 
outward  to  the  inner  surface  of  the  ramus,  while  the  masseter  passes 
downward,  backward,  and  relatively  inward  to  its  outer  surface.  The 
masseter  being  the  most  powerful  may,  in  fractures  in  front  of  the 
angle,  cause  an  outward  tiltmg  of  the  lower  end  of  the  ramus.  In  a 
fracture  at  the  angle  the  pull  of  the  mandibulohyoid  muscles  will  tend 
to  draw  the  body  backward.  If  a  considerable  part  of  the  masseter 
and  internal  pterygoid  muscles  remains  attached  to  the  posterior  end 
of  the  body  fragment,  this  may  be  drawn  upward,  so  that  the  lower 


Fig.  33.  Diagram  showing  possible  forward  displacement  of  the  ramus  in  fracture 
of  the  body  at  the  angle. 

posterior  molar  tooth  is  locked  behind  the  corresponding  upper,  the 
chin  is  depressed,  and  the  lower  incisors  do  not  come  up  to  occlusion. 
In  a  fracture  of  the  posterior  part  of  the  body,  unless  prevented  by 
the  direction  of  the  break  or  the  presence  of  one  or  more  occluding 
teeth  in  the  posterior  fragment,  the  lower  end  of  the  ramus  may  be 
tilted  forward  and  possibly  laterally.  The  direction  of  the  lateral  dis- 
placement will  depend  upon  the  direction  of  the  break  (Figs.  27  to  33). 

In  fractures  of  the  ramus  itself,  there  is,  as  a  rule,  little  or  no 
displacement  (Fig.  34),  but  a  fractured  coronoid  process  may  be  drawn 
upward  and  backward  by  the  temporal  muscle.  In  a  fracture  of  the 
neck  between  the  ramus  and  the  attachment  of  the  external  pterygoid, 
the  condyle  may  be  drawn  forward  by  the  latter  muscle. 

The  hyoid  bone  is  not  fixed,  but  its  position  depends  upon  the  tone 
of  the  various  muscles  to  which  it  furnishes  attachment ;  therefore  the 


98 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


act  of  swallowing,  talking,  or  even  moving  the  head  will  often  influence 
both  the  pain  and  the  displacement  of  a  fracture  in  the  body  of  the 
lower  jaw.  In  fractures  with  loss  of  substance  this  is  always  magni- 
fied. 

Diagnosis. — Where  any  considerable  number  of  opposing  teeth 
are  present,  the  diagnosis  of  a  fracture  of  the  body  is  usually  self-evi- 
dent, even  though  the  displacement  be  slight.  In  fractures  behind  the 
angle  and  in  fractures  of  the  body  with  no  displacement,  diagnosis  is 
usually  best  made  by  the  use  of  the  x-ray  and  the  noting  of  points 
of  greatest  tenderness.  Sometimes  there  is  sufficient  displacement  to 
be  recognized  by  palpation,  but  crepitus,  the  sensation  elicited  from  the 
grating  together  of  the  broken  fragments,  is  rarely  a  factor  in  making 


Fig.  34.  X-ray  of  fracture  of  the  ramus,  sustained  by  falling  on  the  ,  face.  There 
was  no  displacement  of  the  body,  and  the  exact  nature  of  the  injury  was  determined  only 
by  the  x-ray.  No  fixation  was  needed  in  the  treatment,  as  there  was  little  pain  and  no 
displacement.     The  fracture  is  to  be  seen   at  the  left  side  of  the  picture. 


the  diagnosis.  If  true  bony  crepitus  is  detected,  it  is  to  be  taken  as 
certain  evidence  of  a  fracture,  but  crepitus  is  to  be  sought  only  by  the 
gentlest  of  manipulations. 

A  good  x-ray  gives  the  most  accurate  information  with  least  in- 
convenience to  the  patient,  but  usually  a  fracture  may  be  recognized 
or  excluded  by  seeking  for  localized  points  of  greatest  tenderness. 
If  a  point  along  the  jaw-bone  is  found  to  be  tender  to  finger 
pressure,  it  may  mean  that  there  is  a  fracture  at  this  site,  or  simply 


FRACTURES  OF  THE  LOWER  JAW.  99 

that  there  is 'a  localized  bruise.  If,  however,  pressure  upon  the  jaw- 
bone at  several  different  points  causes  distant  pain  at  one  certain  point, 
that  is  also  sensitive  to  local  pressure,  then  this  may  be  taken  as  strong 
evidence  of  a  fracture  at  this  site.  For  instance,  in  a  fracture  at  the 
symphysis,  there  may  be  absolutely  no  displacement,  but  the  chin  will 
be  found  tender  to  pressure;  and  pressure  on  the  jaws  at  the  angles 
will  cause  discomfort  at  the  chin,  owing  to  the  force  being  transmitted 
through  bone  to  the  site  of  fracture.  If  the  site  of  suspected  frac- 
ture is  near  or  above  the  angle,  the  test  is  made  by  pushing  the  chin 
backward  and  drawing  it  from  side  to  side. 

The  lower  jaw  is  the  most  accessible  of  all  the  bones  in  the  body, 
and  deformities  resulting  from  the  malunion  of  the  fractures  are  in 
themselves  more  noticeable  than  in  almost  any  other  part. 

TREATMENT. 

Treatment  of  a  fracture  of  the  lower  jaw  includes  two  objects: 
the  care  of  the  tissues  and  of  the  patient,  and  the  replacement  and 
maintenance  of  the  correct  position  of  the  fragments.  Of  these,  the 
latter  will  be  considered  first.  There  are  two  ways  of  keeping  the 
fragments  in  the  correct  position.  One  is  to  hold  the  broken  frag- 
ments in  their  proper  relation  to  the  sound  jaw  and  thus,  indirectly, 
with  each  other;  and  the  other  is  by  means  of  dental  splints,  wires, 
or  bone  plates  to  directly  fix  the  broken  fragments  to  each  other. 

Indirect  Fixation. — It  has  long  been  recognized  that  where  there 
is  a  full  or  nearly  full  quota  of  teeth  the  dental  arch  of  the  uninjured 
jaw  should  make  an  ideal  splint  for  the  fractured  jaw,  if  adequate 
means  could  be  contrived  to  hold  the  two  arches  in  occlusion.  The 
older  and  very  commonly  recommended  method  of  applying  a  chin 
cup  and  bandaging  the  lower  to  the  upper  jaw  with  a  Barton  or  a  four- 
tailed  bandage  is  seldom  efficient  where  there  is  any  displacement.  Hip- 
pocrates recognized  that  this  was  not  applicable  to  certain  forms  of 
fracture.  Any  bandage  or  apparatus  that  presses  backward  on  the  chin 
can  tend  only  to  produce  displacement,  and  extensive  observation  has 
proved  that  about  equally  good  or  bad  final  results  are  obtained  by 
no  treatment  as  by  this  method.  With  any  form  of  fixation,  a  ban- 
dage, for  a  few  days,  will  give  a  sense  of  security  that  is  grateful  to 
the  patient.  In  case  of  fracture,  in  which  there  is  no  tendency  to  dis- 
placement, rest  is  all  that  is  required  (Fig.  34),  and  this  may  be  at 
least  partially  secured  by  a  broad  chin  bandage. 

The  use  of  a  cotton  and  rubber  elastic  bandage  or  a  broad  strip 
of  rubber  dam  passed  under  the  chin,  when  not  applied  too  tightly, 
is  more  effective  and  more  comfortable  than  an  inelastic  bandage. 

There   are  a    few   cases   when  an   elastic   chin  bandage  will  ac- 


100 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


complish  more  than  can  be  done  with  sphnts  and  it  is  frequently  a 
good  supplementary  support. 

Direct  Fixation. — This  may  be  done  by  uniting  the  ends  of  the 
bones  by  means  of  wires,  absorbable  sutures,  or  metal  plates,  or  by 
means  of  dental  splints.  It  is  seldom  that  a  fracture  of  the  ramus 
will  require  direct  fixation.  These  are  rarely  open  fractures,  and  the 
broad  muscular  attachment  on  its  surface  usually  prevents  displace- 
ment when  the  body  is  held  in  its  normal  position.  In  front  of  the 
angle  and  in  the  body,  the  displacement  at  times  necessitates  the  use 
of  direct  bone  fixation. 

Fixing  of  the  Lower  to  the  Upper  Jaw. — It  is  to  the  dental 
profession  that  we  owe  many  of  the  devices  that  will  accomplish  the 
fixation  of  jaw  fragments  with  certainty.  At  least  it  is  certain  that 
by  the  members  of  this  profession  these  means  have  been  perfected 


Fig.    36. 


Fig.    35. 


Fig.  35.  Diagram  showing  fracture  treated  by  wiring  the  lower  to  the  upper  jaw 
by  means  of  Angle  fracture  bands. 

Fig.  36.  Gilmer's  method  of  treating  a  fracture  of  the  body  by  fastening  the  lower 
to  the  upper  jaw  by  means  of  wires  passed  around  the  necks  of  the  teeth. — Prom  "Oral 
Surgery." 

and  popularized.  To  Dr.  Thomas  L.  Gilmer,  of  Chicago,  the  dentist 
owes  the  simple  but  extremely  useful  device,  the  soldered  dental 
band,  which  consists  of  a  band  of  thin  metal  made  to  conform  to 
the  circumference  of  the  crown  and  which  is  cemented  in  place.  To 
it  may  be  soldered  a  ring,  tube,  or  a  bar.  When  properly  applied, 
these  bands  cause  no  damage  to  the  teeth,  and  will  remain  in  place 
rather  indefinitely.  The  adjustable  band,  which  dates  back  to  the 
early  part  of  the  last  century,  can  be  applied  and  tightened  with  a 
wrench.  Under  the  name  of  Angle's  fracture  bands,  these  may  be 
obtained  from  the  dental  supply  houses  in  two  sizes,  one  to  fit  the 
cuspid  and  bicuspid  and  the  other  for  the  molar  teeth.  There  is 
another  adjustable  band  also  furnished  by  supply  houses,  modified 
by  Lukens. 


FRACTURES  OF  THE  LOWER  JAW. 


101 


So  far  as  we  know,  Dr.  Gilmer  first  advocated  the  direct  fixation 
of  the  lower  to  the  upper  jaw  by  means  of  the  teeth  as  a  treatment  of 
fracture  of  the  mandible.^  Where  appHcable,  this  is  a  very  simple 
procedure,  is  efficient,  and  has  a  broader  field  of  usefulness  than 
any  other  means  at  the  disposal  of  either  the  surgeon  or  the  den- 
tist. The  fixation  may  be  done  by  dental  bands  (Fig.  35),  or  by  wires 
fastened  directly  to  the  necks  of  the  teeth  (Fig.  36).  If  bands  are 
used,  the  jaws  are  fixed  by  silk  or  fine  wire  ligatures  that  extend  be- 
tween the  bands,  each  having  a  lug  or  button  on  its  outer  surface  for 
this  purpose.  The  use  of  bands  has  certain  points  in  its  favor  over 
the  direct  wiring  of  the  teeth,  but  the  latter  is  the  more  practical  meth- 
od ;  the  materials  required  are  nearly  always  at  hand,  and  can  be  ap- 
plied by  any  surgeon  with  a  pair  of  artery  forceps  and  a  pair  of  scis- 
sors or  wire  cutters.     There  is   this  disadvantage  in  the   method :  in 


Pig.  37.  Double  fracture  of  lower  jaw.  Anterior  fragment  held  up  by  wires  pass- 
ing from  lower  bicuspids  to  upper  cuspids.  As  there  is  always  a  tendency  to  a  back- 
ward displacement,  one  tooth  below  on  each  side  should  be  wired  to  a  tooth  above  and 
in  front  of  it.  The  discoloration  of  the  teeth  is  due  to  the  iron  wires.  This  is  an  ob- 
jection,  but  the   teeth  can   be   cleansed. 

order  to  open  the  mouth  the  wires  have  to  be  cut,  and  if  it  is  found 
desirable  to  continue  the  fixation,  the  whole  procedure  might  be  re- 
peated on  teeth  that  are  sore  from  traction.  However,  if  one  will 
refrain  from  the  exercise  of  unwarranted  curiosity,  the  necessity  of 
reapplying  the  wires  v.'ill  not  often  arise.  The  wire  which  we  prefer 
is  a  soft  iron  wire  that  can  be  obtained  on  spools  from  the  hardware 
shop,  or  in  rolls  at  any  florist's,  using  No.  24  for  the  molars  and  canines, 
and  No.  26  for  the  incisors.  This  iron  wire  is  very  pliable  and 
does  not  stretch,  but  if  it  cannot  be  obtained,  a  soft  brass,  copper,  or 
silver  wire  may  be  substituted.  The  wire  is  cut  into  lengths  of  about 
45  centimeters  each,  is  bent  in  the  middle,  and  by  means  of  forceps  is 
passed  from  the  lingual  surface  through  the  interdental  spaces  on  each 
side  of  the  tooth  to  be  ligated.     An  assistant  holds  the  loop  of  the 

*  Thomas  L.   Gilmer:     Archives  of  Dentistry,   September,   1887. 


102  SURGERY  OF  THE  MOUTH  AND  JAWS. 

wire  well  down  on  the  lingual  side  of  the  neck  of  the  tooth,  while 
the  operator,  having  obtained  a  firm  grasp  on  each  end,  makes  a 
twist  of  two  full  turns.  This  is  the  most  important  part  of  the 
application  of  the  wire  ligature.  It  should  grasp  the  neck  of  the 
tooth  so  firmly  as  to  preclude  any  motion.  The  ligature  can  be 
tightened  with  forceps,  but  it  is  better  to  get  the  tension  while  the 
first  twist  is  being  made.  The  serrations  on  the  jaws  of  the  forceps 
weaken  the  wire  wherever  they  grasp  it.  The  subsequent  steps  may 
be  understood  by  referring  to  Fig.  36,  or  Fig.  37,  which  show 
the  completed  operation.  While  the  upper  wires  are  being  twisted 
with  the  lower,  the  teeth  should  be  held  in  occlusion  by  pressure 
from  below  the  chin.  It  is  extremely  important  that  the  teeth  be 
held  in  proper  occlusion  while  the  wires  are  being  tightened.  Wire 
ligatures  put  in  by  this  method  will  not  slip  or  become  untwisted ; 
but  the  incisor  teeth  offer  poor  anchorage,  and,  owing  to  the  slight 
constriction  at  its  neck,  the  canine  is  a  difficult  tooth  to  wire. 

Lately  Gilmer  has  modified  this  procedure  in  a  way  that  allows 
the  jaws  to  be  opened  and  rewired  without  disturbing  the  wires 
that  ligate  the  teeth  themselves.  A  fairly  stiff  arch  wire  is  applied  to 
the  labial  surfaces  of  the  teeth  of  each  jaw,  with  its  end  bent  a 
little  around  the  last  teeth  to  which  attachment  is  made.  The  arches 
are  fastened  by  fine  ligature  wire  threaded  between  and  around  the 
teeth.  The  upper  and  lower  jaws  are  fixed  in  occlusion  by  means 
of  ligature  wires  passing  between  the  upper  and  lower  arches.  By 
cutting  these  ligatures  the  mouth  can  be  quickly  opened  when  neces- 
sary, a  very  important  point  in  some  cases  where  free  drainage  and 
cleansing  are  necessary,  and  where  ankylosis  is  feared. 

If  the  line  of  fracture  is  through,  or  just  in  front  of,  the  canine 
socket,  it  often  happens  that  a  good  purchase  cannot  be  had  on  the 
teeth  of  the  anterior  fragment.  Under  these  circumstances,  we  pass 
a  silver  wire  around  the  body  of  the  anterior  fragment  and  fasten 
it  to  an  upper  cuspid  (Fig.  38).  Dr.  Black  passed  a  wire  around 
the  body  of  the  jaw  and  around  a  splint  on  the  lower  teeth.  Either 
of  these  methods  can  be  done  with  a  local  anesthetic. 

The  lower  may  be  fastened  to  the  upper  jaw  through  the  medium 
of  swaged  metal  jackets  for  each  jaw,  covering  the  upper  and  lower 
teeth.  The  splints  of  each  jaw  are  provided  with  hooks  or  buttons 
at  several  points  on  the  labio-buccal   surfaces. 

After  being  cemented  in  ]josition,  the  U])per  and  lower  jackets 
can  be  fixed  together  with  the  teeth  almost  in  occlusion  by  means 
of  ligature  wires  passed  around  the  hooks  or  Ijuttons.  Where  it  is 
desirable  to  fix  the  jaws  in  a  partly  open  position,  vulcanite  blocks 
can  be  inserted  between  the  upper  and  lower  metal  pieces,  the  blocks 


FRACTURES  OF  THE  LOWER  JAW. 


103 


being  provided  also  witli  buttons  for  ligature  wire  attachment.  This 
splint  is  especially  adaptable  in  cases  where  it  may  be  necessary  to 
open  the  mouth  from  time  to  time. 

When  possible,  it  is  preferable  to  have  the  teeth  cleansed  of  all 
tartar  before  applying  bands  or  ligatures.  No  matter  hov^  desirable 
this  may  be,  it  is  not  always  practical  to  do  so.  But  in  any  case  an 
efficient  mouth  wash  should  be  constantly  employed.  The  wires,  less 
so  the  bands,  are  liable  to  set  up  a  simple  gingivitis,  but  this  usually 
at  once  subsides  on  their  removal. 

The  teeth  upon  which  traction  has  been  made  become  loose  in  their 


Fig.  38.  X-ray  showing  a  silver  wire  passed  around  tlie  mental  portion  of  the  body 
of  the  jaw  and  fastened  to  a  wire  on  the  cuspid  above.  This  holds  the  bone  up  very 
satisfactorily.  The  dark  spots  in  the  orbit  are  shot  received  years  before,  and  causing 
no  symptoms. 


sockets,  but  tighten  up  within  a  few  days  after  the  traction  is  released. 
Whether  bands  or  wire  ligatures  are  used,  the  sharp  ends  and  corners 
are  irritating  to  the  inner  surface  of  the  cheeks  and  lips.  A  very  ef- 
ficient and  easily  obtainable  protective  is  a  gum  formed  by  heating 
gutta-percha  tissue  over  a  flame  until  it  melts  into  a  mass,  and  then 
with  wet  fingers  molding  it  over  the  projecting  wires  (Fig.  39). 

If  the  teeth  are  wired  while  the  patient  is  under  a  general  anes- 


104 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


thetic,  the  stomach  should  be  emptied  by  means  of  a  tube  before  the 
jaws  are  fixed  together.  Even  if  the  patient  has  not  eaten  recently, 
there  may  be  blood  or  food  in  the  stomach.  It  is  an  easy  and  safe  pro- 
cedure to  pass  a  tube  and  wash  out  the  stomach  while  the  patient  is 
slightly  under  the  anesthetic.  Though  it  is  our  custom  to  leave  an 
attendant  to  sit  with  wire  cutters  after  such  an  operation,  we  have 
never  seen  it  necessary  to  cut  the  wires.  The  patient  will  not  vomit 
until  the  pharyngeal  reflexes  are  restored ;  then,  if  the  stomach  contents 
are  fluid,  they  will  be  emitted  between  the  teeth  or  from  the  nose. 

Operation  for  Wiring  the  Bone  for  a  Fracture  at,  or  in  Front  of, 
the  Angle. — The  skin  having  been  cleansed  and  shaved,  an  incision 
is  made  under  the  border  of  the  jaw  4  or  5  centimeters  long.  If  this 
incision  is  continued  on  the  posterior  border  of  the  ramus  for  any  dis- 
tance beyond  the  angle,  care  should  be  taken  not  to  endanger  the 
trunk  of  the  facial  nerve  which  crosses  the  posterior  border  of  the 


Fig.   39.      Photograph    showing    gutta-percha    gum    covering    the    wires. 


ramus  at  the  level  of  the  lower  border  of  the  lobe  of  the  ear.  The 
incision  extends  directly  to  the  border  of  the  jaw  throughout  its  whole 
extent,  and  the  facial  artery  and  vein  are  cut  at  the  anterior  border  of 
the  masseter  muscle.  These  vessels  should  be  caught  with  artery  for- 
ceps before  being  cut,  and  tied  immediately  after  they  are  severed. 
The  inframandibular  branch  of  the  facial  nerve  will  often  be  divided 
by  this  incision. 

The  bleeding  from  small  vessels  in  the  tissues  is  always  very  free 
and  should  be  controlled.  With  a  knife,  not  with  a  periosteal  elevator, 
the  soft  tissues,  exclusive  of  the  periosteum,  are  raised  from  both  sur- 
faces of  the  bone  for  a  distance  of  at  least  1  centimeter  from'  the  lower 
border  and  2  centimeters  on  each  side  of  the  fracture.  The  insertions 
of  the  masseter  and  internal  pterygoid  muscles  must  be  cut  from  the 
bone,  but  in  no  place  should  the  bone  be  actually  bared.  ?s  this  would 


FRACTURES  OF  THE  LOWER  JAW.  105 

lessen  its  vitality.  The  most  advantageous  position  for  the  drill  holes 
should  be  selected  according  to  the  direction  of  the  lines  of  fracture. 
The  drill  holes  should  not  be  closer  than  5  millimeters  from  the  line 
of  fracture  or  from  the  lower  border  of  the  bone. 

At  least  in  a  general  way,  the  wire  suture  should  cross  the  line 
of  fracture  at  right  angles.  Sometimes,  in  fractures  that  are  oblique 
to  the  surface  of  the  bone,  it  is  possible  to  make  each  drill  hole  pierce 
both  fragments. 

While  the  bone  is  being  drilled,  it  should  be  held  with  toothed 
forceps  that  will  grasp  the  bone  without  crushing  or  scraping  its  cov- 
erings. A  flat  retractor  or  a  piece  of  flat  metal  should  be  held  be- 
neath the  bone  to  prevent  the  drill  from  piercing  the  soft  tissues.  When 


Fig.  40.  Diagram  stiowing  method  of  passing  the  wire  from  the  deep  surface  of 
the  bone.  The  silver  wire  is  passed  through  the  first  hole  from  the  external  to  the 
mesial  surface.  Next  a  loop  of  finer  wire  is  passed  through  the  second  hole  in  the  same 
way,  and  the  first  wire  is  caught  in  the  loop  of  the  second  and  drawn  through  the  second 
hole. 

one  hole  is  drilled,  the  wire  should  be  immediately  inserted,  or  a  piece 
of  bent  wire  should  be  placed  in  the  hole  temporarily;  otherwise  it 
will  become  lost  to  view.  The  drill  holes  should  be  large  enough  to 
admit  the  wire  doubled.  A  convenient  method  of  inserting  the  wire 
is  shown  in  Fig.  40.  A  piece  of  soft  silver  wire  about  No.  20  should 
be  used.  We  are  not  convinced  that  the  braided  Vienna  wire,  which 
is  a  cord  made  of  fine  silver  wires  twisted  together,  is  superior  or  even 
equal  to  the  ordinary  soft  virgin-silver  wire  (Fig.  41). 

The  wound  is  sutured  with  a  few  figure-of-eight  silkworm  gut 
sutures,  the  deep  loops  of  which  take  a  good  hold  on  the  cut  cervical 
fascia.  A  small  drainage  tube  or  a  folded  piece  of  rubber  dam  tissue 
is  inserted  under  the  deep  surface  of  the  bone  to  the  line  of  fracture, 


106 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


and  caug-ht  in  the  wound  with  a  suture.  Such  wounds  are  usually  in- 
fected by  communicating  with  the  mouth,  but  osteomyelitis  seldom  re- 
sults from  a  fracture  of  the  jaw.  The  wound  will  usually  heal  with  the 
wire  in  place.  Sometimes  it  will  be  thrown  ofif,  but  it  is  rare  that  it 
will  have  to  be  removed  for  a  persistent  sinus. 

Lane's  Plates. — Instead  of  using  wire,  the  fragments  may  be 
fixed  by  the  use  of  a  small  steel  plate,  2  millimeters  thick,  5  millimeters 
wide,  and  2  centimeters  long,  which  has  a  countersunk  hole  in  each 
end.  This  is  fastened  to  the  bone  by  ordinary  wood  screws,  the  thread 
of  which  is  cut  up  to  the  shoulder.  This  procedure  is  seldom  if  ever 
advisable. 


K^'^'  X-ray  of  a  jaw  broken  just  in    front  of  the  angle  on   one  side   and  behind 

the  bicuspid  teeth  on  the  other,  with  no  teeth  in  either  posterior  fragment.  Both  frac- 
tures wired  through  the  bone,  and  the  teeth  in  the  anterior  fragment  wired  to  those 
above. 


Operation  of  Wiring  the  Jaw  at,  or  in  Front  of,  the  Second 
Molar  Tooth. — At,  or  in  front  of,  the  second  molar  tooth,  the  jaw 
may  be  conveniently  wired  from  within  the  mouth.  The  cheek  is  re- 
tracted, and  an  incision  3  or  4  centimeters  long  is  made  through  the 
mucous  membrane  at  the  bottom  of  the  fornix  of  the  vestibule.  With- 
out raising  the  periosteum,  the  incision  is  carried  through  the  attach- 
ment of  the  buccinator  muscle,  nearly  down  to  the  inferior  border  of 
the  jaw.  A  strip  of  gauze  is  packed  into  the  wound,  and  a  shorter 
incision  is  made  on  the  inner  surface  of  the  bone  at  the  junction  of  the 
gum  with  the  mucous  covering  of  the  floor  of  the  mouth.  This  in- 
cision is  made  directly  to  the  bone,  and  to  avoid  injury  to  the  struc- 
tures in  the  floor  of  the  mouth,  particularly  the  lingual  nerve,  the  point 
of  the  knife  should  never  leave  the  bone.     A  spatula  is  placed  in  the 


FRACTURES  OF  THE  LOWER  JAW.  107 

inner  incision  to  protect  the  soft  structures  from  the  drill.  The  wiring 
may  be  done  either  through  the  alveolar  process  or  through  the  body. 
The  bone  may  be  much  more  conveniently  wired  through  the  alveolus 
and  without  a  general  anesthetic,  but  the  result  is  not  quite  so  satis- 
factory. In  an  oblique  fracture,  to  have  the  wire  cross  the  line  of 
break  at  right  angles,  it  may  be  necessary  to  put  one  hole  through  the 
alveolus  and  one  through  the  body  of  the  bone.  When  the  alveolus  is 
drilled,  care  should  be  taken  not  to  injure  the  roots  of  the  teeth.  A 
tooth,  the  root  of  which  is  injured  by  the  drill,  may  later  have  to  be 
devitalized  and  filled. 

After  the  wire  is  twisted,  the  bottom  of  the  wound  is  drained  from 
below,  through  a  small  external  stab,  by  means  of  a  drainage  tube  or 
a  piece  of  rubber  dam  which  is  stitched  to  the  skin.  The  wound  may 
be  packed  with  gauze  to  control  the  hemorrhage.  If  the  lower  jaw 
is  to  be  wired  to  the  upper,  the  inner  packing  must  be  removed 
before  this  is  done. 


Fig.    42. 

Fig.  42.  Hammond  wire  splint.  One  of  the  earlier  dental  splints,  but  now  little 
used  in  this  country. 

In  wiring  a  fracture  at  the  symphysis,  the  attachment  of  the  genio- 
hyoglossi  muscles  must  not  be  cut,  as  this  would  leave  the  tongue  with- 
out anterior  anchorage.  Bone  fixation  should  never  be  resorted  to 
where  a  dental  splint  or  wiring  the  lower  to  the  upper  jaw  can  be  con- 
veniently substituted. 

Dental  Splints. — Probably  the  earliest  attempt  at  making  a 
dental  splint  was  to  fasten  the  teeth  on  both  sides  of  the  fracture  to 
each  other  by  means  of  a  ligature  crossing  the  site  of  fracture.  Hip- 
pocrates recognized  that  to  be  efficient  the  ligature  must  be  attached  to 
teeth  not  immediately  adjacent  to  the  break.  The  use  of  the  wire 
in  this  position  is  much  more  efficient  if  it  is  made  to  completely 
encircle  the  neck  of  each  included  tooth  in  turn. 

The  Hammond  splint  (Fig.  -1:2)  is  still  shown  in  many  text  books, 
but.  useful  as  it  was  before  the  development  of  modern  dental  technic, 
other  devices  now  replace  it. 


108 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Lately,  however,  there  has  been  a  tendency  to  adopt  modifications 
of  this  device.  Tigerstedt,  of  Kieff,  has  ampHfied  Hammond's  idea 
to  make  it  fulfill  the  uses  of  many  of  the  complicated  devices  that 
have  been  found  advantageous  in  treating  the  gunshot  fractures  with 
loss  of  bone  so  frequently  encountered  in  the  present  war  (See 
Figs.  43  and  44). 


Fig.  43.  Splint  for  fracture  and  loss  of  bone  in  incisor  region,  a,  Compensation 
loops.  (This  is  an  elaboration  of  the  idea  upon  which  the  old  Hammond  splint  is  based.) 
— After  Tigerstedt. 


Fig.  44.      Inclined  plane. — After  Tigerstedt. 

Modern  dental  splints,  as  a  rule,  require  the  technical  skill  of  the 
dentist  for  their  construction  and  must  be  made  for  the  individual  case. 
There  have  been  a  number  of  adjustable  stock  splints,  placed  at  the 
disposal  of  the  medical  profession,  but  these  are  not  likely  to  be  at 
hand  when  needed,  and  less  likely  to  give  really  good  service.  The 
first  requisite  in  the  construction  of  a  dental  splint  is  an  accurate  re- 
production of  the  dental  arches  and  gums  of  both  jaws.     These  are 


FRACTURES  OF  THE  LOWER  JAW. 


109 


made  from  impressions  taken  in  plaster  of  Paris,  modeling  compound, 
or  wax.  From  an  accurately  made  negative  impression,  a  dentist  who 
has  never  seen  the  case  could  pour  the  positive  casts,  reconstruct  the 
broken  arch,  and  make  a  perfect  fitting  splint.  All  except  those  splints 
which  are  banded  to  the  teeth  can  be  applied  by  the  surgeon.  We 
could  not  better  present  this  part  of  the  subject  than  to  quote  Dr.  Gil- 
mer's description  of  his  method  of  taking  impressions  and  reconstruct- 
ing the  deformed  arch : 

"Preparatory  to  the  formation  of  a  splint,  it  is  necessary  to  secure  cor- 
rect impressions  of  both  upper  and  lower  teeth  and  jaws.  The  upper  may 
be  taken  in  plaster  alone,  but  the  lower  can  be  better  and  more  accurately 
made  by  first  taking  it  in  modeling  composition;  from  the  inner  surface 
of  this,  a  small  portion  is  cut  away,  plaster  substituted  in  the  place  of  the 
composition  removed,  and  the  whole  is  again  placed  over  the  teeth.  An 
impression  thus  secured,  if  well  done,  will  be  correct  and  sharp.     By  this 


Fig.    47. 

Fig.  45.  Showing  plaster  reproduction  of  dental  arch  and  alveolar  process  in  a 
fracture  of  lower  jaw.  Irregularities  in  alignment  are  shown  at  the  sites  of  fracture 
behind  the  right  second  bicuspid  and  at  the  site  of  the  left  first  bicuspid. — ^After  Gilmer. 

Fig.  46.  Showing  plaster  reproduction  of  the  dental  arch  and  alveolar  process  of 
the  lower  jaw,   sawed,   ready   for  adjustment. — After   Gilmer. 

Fig.  47.  Showing  complete  reproduction  in  plaster  of  Paris  of  both  dental  arches 
and   alveolar   processes. — After   Gilmer. 

means  an  impression  cup  of  modeling  composition  is  produced,  which  fits 
the  part,  and  very  materially  simplifies  the  operation.  The  sharper  these 
impressions,  the  greater  the  certainty  of  a  true  occlusion  after  the  union  of 
the  fragments.  The  lower  impression  may  be  made  either  in  sections  or 
entire,  according  to  the  case  in  hand;  of  the  comparative  expediency  of 
these  two  methods  the  operator  must  judge  for  himself.  If  the  displace- 
ment be  so  great  as  to  render  it  improbable  that  a  good  impression  may  be 
secured  in  entirety,  it  is  better  to  take  it  in  sections.  In  taking  the  im- 
pression of  the  lower  jaw  it  is  useless  to  attempt  to  hold  the  parts  in  posi- 
tion, since  the  setting  of  the  bone  will  be  done  after  the  appliance  is  made; 
therefore,  all  time  given  this  effort  will  be  lost,  besides  in  the  majority  of 
cases  it  is  impossible  to  hold  the  parts  in  position  while  the  impression  is 
secured.     From  these  impressions  models  are  to  be  made   (Fig.  45).     If 


110  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  impression  has  been  secured  in  one  piece,  the  cast  from  it  is  to  be 
sawed  in  two  on  a  line  with  the  fracture  (Fig.  46).  The  teeth  of  these 
two  pieces  are  then  carefully  occluded  with  those  of  the  upper  model 
(Fig.  47). 

"This  is  easily  done,  even  though  several  teeth  of  each  jaw  are  missing, 
as  there  is  always  an  abraded  surface  of  the  teeth  of  one  jaw  which  ex- 
actly corresponds  with  that  of  the  other,  but  the  greatest  care  must  be 
exercised  in  fitting  the  parts  together,  as  success  depends  upon  the  cor- 
rectness of  this  part  of  the  operation.  If  but  the  slightest  difference  is 
made  in  the  occlusion,  failure  of  perfect  adaption  is  almost  certain  to 
ensue,  as,  the  fragments  not  being  held  squarely  together,  an  undue  pres- 
sure will  be  brought  to  bear  upon  them  at  one  point,  while  at  another  they 
will  not  touch;  consequently,  at  that  point  where  there  is  too  great  pres- 
sure, inflammation  will  set  in,  and  death  of  the  bone  will  follow.  Union 
may  take  place,  but  if  it  does,  the  occlusion  will  be  faulty.  When  the 
occlusion  of  the  teeth  of  the  two  pieces  is  made  with  the  teeth  of  the 
upper  cast,  those  representing  the  broken  lower  jaw  are  to  be  united  by 
the  addition  of  a  little  soft  plaster.  If  the  work  has  been  done  well,  this 
reconstructed  model  represents  the  jaw  as  it  was  previous  to  the  acci- 
dent. The  foregoing  description  of  impressions  and  models  holds  good 
either  in  single,  double  or  triple  fractures,  unless  the  impressions  have  been 
taken  in  sections,  in  which  case  there  is  no  division  of  casts  to  be  made." 

Guilford^  pointing  out  certain  difficulties  that  may  be  encountered 
in  the  above  method,  describes  an  anatomical  articulator  by  which 
the  fragments  can  be  more  certainly  reassembled  to  conform  to. 
occlusion. 

"The  weak  point  in  this  method  is  that  it  is  based  on  the  assumption 
that  the  occlusion  had  been  correct  before  the  fracture.  There  are  many 
cases  in  which  the  occlusion  was  previously  far  from  perfect,  and  in 
these  cases  it  is  practically  impossible  to  place  accurately  the  pieces  of 
the  lower  model.  It  is  a  simple  matter  to  reassemble  the  cut  model 
so  that  the  occlusion  will  be  satisfactory,  but  it  must  be  remembered  that 
these  plaster  fragments  must  also  be  placed  in  their  correct  anatomical 
positions.  Any  fragment  which  is  fractured  at  both  ends  may  be  placed  in 
occlusion  without  danger  of  disturbing  the  temporo-mandibular  articula- 
tion, but  those  pieces  which  are  continuous  with  the  rami  must  not  only 
be  brought  into  occlusion,  but  they  must  also  be  placed  so  that  their 
anatomical  positions  are  correct. 

"Figs.  48  and  49  show  two  views  of  a  fractured  mandible  which  is 
in  malposition.  It  is  evident  that  if  the  pieces  of  this  mandible  are  to 
be  placed  in  their  correct  positions,  they  must  be  moved  in  a  very  definite 
manner.  That  is  to  say,  they  must  be  'swung,'  and  the  center  of  rota- 
tion must  be  the  middle  of  the  articulating  surface  of  the  condyle.  If 
the  pieces  of  the  cut  lower  model  are  not  'swung'  in  exactly  the  same 
manner  the  reposed  or  corrected  model  will  not  represent  the  mandible 
in  normal  articulation. 

"In  the  method  in  which  occlusion  is  the  only  guide  in  this  very 
complex  and  exact  problem  of  reposing  the  lower  model,  the  possibilities 


iGuilford :      Dental    Cosmos,    May,    1916. 


FRACTURES  OF  THE  LOWER  JAW. 


Ill 


of  error  are  so  numerous  that  an  exact  result  is  practically  impossible. 
Any  inaccuracy  in  the  reposed  model  means  that,  when  the  splint  is 
placed  on  the  teeth,  one  or  both  condyles  will  be  forced  from  normal 
articulation. 


Fig.  4S. 
Figs.   48   and   49. 


Two   views  of   fractured   mandible    in   maloposition. 


"In  order  to  overcome  the  large  element  of  'guesswork'  in  this  method, 
the  writer  originated  an  articulator  (see  Fig.  50)  by  means  of  which  it 
is  possible  to  correctly  repose  the  model  of  the  lower  denture  even 
when  the  original  articulation  had  been  very  imperfect.  This  articulator 
was    constructed   in    the   American    Ambulance    at    Neuilly,    France,    and    as 


Fig.    50.      Showing   Guilford's   articulator. 

it  had  to  be  made  in  a  very  primitive   carpenter  shop,  it  is  rather  crude, 
but  it  was   found  to  be  entirely  practical. 

"It    was    made    by    fastening    two    pieces    of    wood    together    at    right 
angles,  and  on  the  piece  which  formed  the  base  a  white   glazed  tile  was 


112 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


held  by  wooden  strips,  as  shown  in  the  illustration.  The  glazed  tile 
gave  a  flat,  smooth  surface  on  which  to  run  plaster  and  move  the  model 
after  it  had  been  cut. 

"On  the  upright  portion,  two  small  pieces  of  wood  (a  and  a')  were 
held  in  position  by  screws  which  passed  through  slots  so  that  these  pieces 
(a  and  a')  could  be  adjusted  laterally.  Below  the  slot  a  hole  was  drilled 
in  each  piece  to  accommodate  a  wire  nail.  These  holes  were  made  large 
enough  so  that  the  nails  (b  and  b')  could  also  be  adjusted  laterally,  and 
they  were  held  in  position  by  screw-eyes  which  acted  as  set-screws.     Three 


pieces  of  3/16"  brass  rod  were  then  bent  as  shown  in  Fig.  50,  and  the 
ends  were  flattened  and  drilled  so  that  they  would  rotate  on  the  wire 
nails.  The  part  designed  to  hold  the  lower  model  was  made  in  two 
pieces  so  that,  after  the  model  had  been  cut,  the  pieces  could  be  in- 
dependently  articulated. 

"In  this  articulator  the  points  c  and  c'  represent  the  centers  of  the 
articulating  surfaces  of  the  two  condyles,  and  as  these  are  the  points 
about  which  the  pieces  of  the  cut  model  must  rotate  in  order  to  re- 
main   in    their    correct    anatomical    positions,    it    is    evident    that    an    exact 


Fig.  52. 


result  is  assured  if  the  models  can  be  correctly  mounted  on  the  articulator. 
"The  models  should  be  mounted  by  using  a  Snow  face-bow  in  the 
following  manner.  The  condyles  must  be  located  as  exactly  as  possible, 
and  the  surface  of  the  skin  marked  directly  over  the  articulating  surface 
of  each  condyle.  A  mush  bite  is  then  taken,  and  the  stem  of  the  face- 
bow  'is  embedded  in  it.  With  the  bite  held  firmly  between  the  teeth  of 
the  patient,  the  clamp  of  the  face-bow  is   slipped  over  the  stem,  and  the 


FRACTURES  OF  THE  LOWER  JAW.  113 

projecting  ends-  of  the  bow  are  brought  in  contact  with  the  marks  on 
the  patient's  skin.  The  clamp  is  then  tightened,  and  the  face-bow,  with 
the   bite   attached,   is   carefully   removed   without   altering   the   adjustments. 

"Before  placing  the  models  on  the  articulator  it  is  necessary  to  ad- 
just the  two  pieces  a  and  a'  so  that  the  distance  between  the  points  c 
and  c'  is  34  mm.  less  than  the  distance  between  the  projecting  ends  of 
the  face-bow.  This  is  necessary  because  the  ends  of  the  face-bow,  when 
in  position  on  the  patient,  rest  on  the  surface  of  the  skin,  and  the  dis- 
tance from  this  point  to  the  center  of  the  condyle  will  average  17  mm. 
on   each   side. 

"The  face-bow  is  placed  on  the  articulator  by  moving  the  wire  nails 
out  until  they  rest  in  the  holes  in  the  end  pieces  of  the  bow,  care  being 
taken  that  the  distance  from  the  end  piece  of  the  face-bow  to  the  point  c 
is  the  same  on  each  side.     (See  Fig.  51.) 

"The  models  are  then  placed  in  position  in  the  bite  and  attached  to 
the  articulator  with  plaster.  The  models  and  face-bow  should  be  re- 
moved by  slipping  the  nails  inward  without  disturbing  the  adjustment  of 
the  pieces  A  and  a'. 


Fig.  53. 

"The  lower  model  is  then  cut  at  the  points  of  fracture,  and  the  pieces, 
together  with  the  upper  model,  are  replaced  on  the  articulator.  (See 
Fig.   52.) 

"If  the  various  steps  in  locating  the  condyles  and  mounting  the  models 
have  been  carefully  taken,  the  points  c  and  c'  will  very  accurately  represent 
the  centers  of  the  articulating  surfaces  of  the  two  condyles,  and  when  the 
plaster  fragments  are  moved,  they  will  always  follow  the  correct  move- 
ments  of   the   corresponding   parts    of   the   mandible. 

"If  the  fragments  of  the  lower  model  are  now  brought  into  occlusion, 
the  articulator  will  automatically  fulfill  the  requirement  that  the  temporo- 
mandibular articulation  must  not  be  disturbed. 

"Fig.  53  shows  the  finished  splint  on  the  reposed  model.  This  was  a 
case  in  which  an  accurately  reposed  model  was  essential,  and  'in  which 
the  occlusion  had  been  very  imperfect  before  the  fracture.  (Note  the 
missing  teeth  and  deflected  median  line  in  the  reposed  model  in  Fig.  52.)" 


114  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Dental  splints  are  formed  in  various  ways,  according  to  the  judg- 
ment of  the  operator  and  the  case  in  hand.  But  those  recommend 
themselves  as  preferable  which  are  most  simple  of  construction,  and 
which  take  up  least  space  in  the  mouth,  having  the  requisite  strength 
and  other  qualities  which  go  toward  making  a  splint  serviceable. 

For  the  construction  of  splints  that  are  to  hold  the  jaws  apart,  as 
the  Gunning  splint  (Fig.  54),  besides  the  impression  of  both  arches 
separately,  a  "mush  bite"  should  be  furnished  to  the  dentist.  This  is 
made  by  taking  a  mass  of  beeswax  made  plastic  by  heat,  which  would 
about  fill  the  patient's  mouth  back  to  the  last  molars,  when  more  than 
half  open.  This  is  placed  in  the  mouth  between  the  teeth,  and  the 
jaws  are  made  to  shut  down  upon  it  until  the  relative  position  of  the 
dental  arches  that  is  to  be  maintained  by  the  splint  is  obtained.  In 
making  this,  the  wax  should  receive  a  good  impression  of  the  teeth' 
in  the  posterior  fragments,  while,  if  a  separate  impression  of  them  has 
already  been  made,  the  anterior  fragment  may  be  disregarded.     The 


Fig.   54. 

Fig.  54.  The  Gunning  splint.  Tliis  is  designed  to  treat  a  fracture  with  tlie  jaws 
separated. 

wax  is  removed  without  distorting  it  and  immediately  placed  in  cold 
water.  From  the  "mush  bit^"  the  dentist  can  gauge  the  proper  rela- 
tionship of  the  maxillary  and  mandibular  halves  of  his  splint. 

Stock  splints  made  on  the  Gunning  idea  of  light  metal  and  fur- 
nished in  various  sizes  are  described  by  Dorrance  and  others.  They 
are  applied  by  filling  an  upper  and  lower  groove  that  receives  each 
dental  arch  with  soft  modeling  compound  and  forcing  the  teeth  deep 
into  the  composition  with  the  fragments  of  the  fractured  arch  in 
relatively  good  positions.  The  chin  is  then  held  up  with  a  chin  cup 
and  an  elastic  chin  bandage. 

These  splints  are  most  applicable  for  temporary  treatment  such 
as  might  be  given  in  an  evacuation  hospital.  The  splint  shown  in 
Fig.  55,  like  the  original  Gunning,  has  the  advantage  of  allowing 
breathing  space  through  the  mouth. 

The  Kingsley  splint  (Fracture  of  the  Alaxilke,  page  91.  Fig.  22) 
is  not  ordinarily  a  very  satisfactory  splint  for  the  lower  jaw,  on  ac- 
count of  the  difficulty  of  securing  it  in  place ;  but  the  Kingsley  and 


FRACTURES  OF  THE  LOWER  JAW. 


115 


other  splints  of  this  class — namely,  those  that  have  a  gutter  correspond- 
ing to  the  alveolar  arch  and  exert  counter  pressure  from  below  the 
chin — all  have  the  advantage  that  they  can  be  used  on  an  edentulous  or 
nearly  edentulous  jaw.  The  arms  on  a  Kingsley  splint  that  protrude 
from  the  mouth  may  be  attached  to  the  plate  of  an  artificial  denture, 
which  would  convert  the  latter  into  a  perfect  fitting  splint. 

Pickerill's  modification  of   Kingsley's  splint   (Fig.  56),  applicable 
for  emergency  service,  is  made  of  a  tray  of  light  metal.     The  arms 


Fig.   55.      Metal  Gunning  splint    (Kelly-Supplee)    for   emergency  fixation  of  fractures 
of  the  jaw  bones.      Gutters  to   be   filled   with   softened   modeling   compound. 

are  made  of  stout  wire  soldered  to  the  body.  The  splints  are  made 
in  three  sizes,  small,  medium,  and  large,  and  the  one  of  the  approxi- 
mate size  required  is  selected.  The  splint  is  first  tried  in  the  mouth 
over  the  teeth,  and  if  too  deep  at  any  point  is  trimmed  with  scissors, 
and  otherwise  adapted  with  pliers.  ]\Iodeling  composition,  softened 
in  hot  water,  is  placed  in  the  splint,  and  the  latter  is  then  pressed  down 
into  position  over  the  teeth  and  jaw,  care  being  taken  that  the  f rag- 


Fig.  56.  Impression  tray  converted  into  a  Kingsley  splint  to  be  used  with  softened 
modeling  composition  in  emergency  treatment  of  injury  to  the  upper  or  lower  jaw. 
Pickerill  has  strongly  advocated  the  use  of  such  splints. 

ments  are  in  normal  position.  A  bandage  is  passed  under  the  mandible 
up  between  each  arm  of  the  splint  and  the  cheek,  over  the  arm  and 
down  under  the  mandible,  where  it  is  tied  firmly. 

Dr.  Hullihan,  a  dentist,  of  Wheeling,  West  Virginia,  described  a 
continuous  dental  splint  which  he  had  constructed  for  a  case  of  re- 
section of  the  alveolus,  which  has  since  often  been  used  for  the  treat- 
ment of  interdental  fractures  of  the  body  (Fig.  57).  It  may  be  made 
of  metal  or  vulcanite,  celluloid  or  hard  rubber,  and  is  modeled  over  a 
plaster  or  metal  reproduction  of  the  dentures.     The  splint  is  supposed 


118 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


to  lit  accurately,  and  is  cemented  into  place.  Such  a  splint  may  in- 
clude all  of  the  teeth  in  the  arch  or  an  adequate  number  on  each  side 
of  the  fracture.  The  antecedent  of  this  splint  was  a  metal  gutter  that, 
in  a  general  way,  closely  conformed  to  the  outline  of  the  dental  arch. 
Wire  ligatures  were  placed  upon  appropriate  teeth,  and  the  ends  of  the 
wires  were  passed  through  the  corresponding  holes  in  the  bottom  of 
the  gutter.  The  splint  was  filled  with  some  sort  of  soft  material  or 
wax  that  would  set,  and,  having  been  forced  into  place,  was  held  by 
twisting  the  wires  together.  Such  a  splint  can  be  constructed  by  a  tin- 
smith, and  might  be  useful  when  a  better  one  cannot  be  obtained,  but 
today  there  are  few  communities  where  the  services  of  a  skilled  dental 
technician  cannot  be  procured. 


Fig.   57.      Hullihan   continuous  dental 
splint. — After  Angle. 


Fig.    58. 


58.      Gilmer  posterior  band 
splint   in   place. 


Considering  its  comparative  simplicity  of  construction,  its  ease  of 
application,  and  its  comfort  to  the  wearers,  the  best  and  most  effective 
of  all  splints  of  this  class  is  the  Gilmer  posterior  band  splint  (Fig.  58), 
the  description  of  which  we  quote  from  the  author : 

"The  least  complicated  splint  that  I  have  seen,  and  one  by  means  of 
which  I  have  achieved  success  in  the  treatment  of  single  fractures,  is 
what  I  have  named  the  posterior  band  splint,  and  was  devised  by  the 
author  in  the  treatment  of  his  first  case  of  fracture  in  1872.  Although  it 
does  not  permit  the  use  of  the  jaw  as  some  others  do,  this  splint  has  an 
advantage  in  its  simplicity  and  claims  favorable  notice  from  the  fact  that 
it  allows  the  occlusion  to  be  seen  at  all  times.  The  posterior  band  splint 
is  made  by  modeling  the  required  shape  in  wax  on  the  lingual  side  of  the 
cast  of  the  teeth  and  jaw,  extending  from  the  last  tooth  back  on  one  side 
to  the  last  tooth  on  the  other,  and  from  the  grinding  surface  down  on  the 
jaw  as  far  as  a  plate  of  teeth  is  usually  allowed.  It  does  not  irritate  the 
tissues  like  a  set  of  artificial  teeth,  as  no  pressure  is  brought  to  bear  upon 
it  downward,  and  muscular  action  does  not  interfere  to  cause  inflammation, 
as  the  muscles  are  at  rest,  or  as  nearly  so  as  possible,  while  the  splint  is 
held  securely  in  place  by  being  fastened  to  the  teeth.     After  being  modeled, 


FRACTURES  OF  THE  LOWER  JAW.  117 

it  is  reproduced  in  vulcanite.  When  the  piece  is  finished,  holes  are  drilled 
into  it  so  it  can  be  wired  to  a  number  of  the  teeth,  or  to  all,  if  thought 
necessary.  The  fracture  is  reduced  by  its  application  to  the  teeth  and  jaw, 
where  it  is  securely  fastened  to  the  teeth  by  wiring.  The  jaws  are  brought 
together  and  held  loosely  by  any  suitable  bandage.  In  a  majority  of  cases, 
either  by  the  loss  of  a  tooth  or  space  between  the  teeth,  there  will  be  suffi- 
cient room  for  the  passage  of  a  liquid  diet.  No  fear  of  poor  adjustment 
need  be  apprehended  therefrom,  as  the  upper  and  lower  teeth  will  be  oc- 
cluded at  all  times,  except  when  the  patient  is  taking  nourishment,  and 
then  but  slightly  parted.  After  a  week,  muscular  contraction  will  be  suffi- 
ciently overcome,  under  favorable  circumstances  a  soft  union  will  have 
taken  place,  and  although  the  splint  be  removed  for  a  short  time,  the  frag- 
ments are  not  liable  to  be  again  displaced;  however,  it  is  not  advisable  to 
remove  it,  but  the  bandage  may  be  still  more  loosely  worn  and  liquid  diet 
changed  for  semiliquid.  With  this  splint  the  occlusion  may  be  seen  at  any 
time  after  its  application,  and  it  may  be  ascertained  whether  it  is  correct  or 
not;  and  if  not,  the  work  may  be  done  over  before  it  is  too  late.  The  teeth 
may  be  cleansed  on  their  buccal  surfaces  at  any  time,  and  on  their  grinding 
surfaces  after  a  week  or  ten  days,  since  after  this  period  the  bandage  may 
be  removed  for  a  few  minutes  with  entire  safety." 


Pig.  59. 

Fig.  59.  Showing  a  modification  of  the  Gunning  splint  that  may  be  used  for  any 
case  in  which  the  jaws  are  to  be  held  apart.  This  is  made  in  two  pieces,  which  are 
fastened  together  after  each  half  has  been  fixed  in  place.  Its  application  is  very  much 
simpler  than  is  that  of  the  original  Gunning  splint. 

In  using  this  splint,  we  have  dispensed  with  the  bandage  ahnost 
from  the  first. 

Effective  splints  of  the  character  we  have  been  considering,  those 
that  fix  the  fracture  by  means  of  spHnts  attached  to  the  teeth  in  the 
broken  jaw,  have  in  common  this  advantage  over  wiring  the  jaws  to- 
gether— that  they  allow  movement  of  the  jaw  almost  throughout  the 
treatment — but  with  the  exception  of  the  Kingsley  and  other  splints 
that  make  counter  pressure  from  the  under  surface  of  the  chin,  they 
are  only  applicable  in  cases  of  interdental  fracture,  with  firm  teeth  in 
each   fragment.     If   it   is   desired  to   overcome  the  pull  of  the   chin 


118 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


muscles  by  dressing  the  mouth  open,  it  may  be  done  by  the  plan  shown 
in  Fig.  59. 

Though  the  forms  already  described  are  more  or  less  applicable  in 
such  cases,  certain  splints  are  more  especially  adapted  to  cases  where 
there  is  a  loss  of  substance  through  the  full  thickness  of  the  bone, 
particularly  in  the  lower  jaw.  There  are  two  broad  classes  of  these 
splints,  first  those  that  have  a  band  of  metal  spanning  the  gap,  at- 
tached by  crowns  or  bands  to  sound  teeth  on  either  side,  and  this 
class  of  splints  is  used  more  particularly  in  cases  where  it  is  hoped 
that  there  will  be  a  spontaneous  regeneration  of  bone,  or  in  which 
it  is  later  intended  to  place  a  bone  or  cartilage  graft  in  the  defect. 

The  second  class  of  splints  have  the  bridge  spanning  the  gap  and 
also  have    a  mass  of    metal  or    vulcanite  or    modeling  composition 


Fig.   60.      Band    and    wire    spliut. — After    Hayes. 


which  fills  the  gap   and   against   which   the   ends   of   the  bone   abut. 
This  splint  is   later   replaced  by   a   partial   denture,   which   carries   a 
corresponding  mass  to  fill  the  gap  as  a  permanent  method  of  deal- 
ing with  the  defect.     This  latter  plan  is  l)ase(l  on  Marten's  idea. 
Splints  of  the  first-mentioned  class  may  be  easily  modified  so  as 


FRACTURES  OF  THE  LOWER  JAW. 


119 


to  exert  continuous  pressure  that  will  expand  the  bone  gap,  in  cases 
when  through  lack  of  proper  early  fixation,  contracture  has  occurred, 
but  in  which  firm  fibrous  scar  tissue  has  not  yet  formed. 

Several  teeth  on  each  fragment  are  fitted  with  ready-made  thin 
copper  bands  of  suitable  size,  trimmed  and  bent  so  as  to  leave  the 
occlusal  surfaces  free.  With  the  bands  in  place,  an  impression  is  taken, 
a  cast  made,  cut  at  the  line  of  fracture  and  reassembled  with  the  lower 
teeth  occluding  properly  with  the  upper.  The  bands  of  each  seg- 
ment are  then  soldered'  to  form  one  piece,  and  the  two  sides  united 


Fig.     61.      Metallic    baud    siilint    to    bridge    defect. — After    Cryer. 


by  soldering  a  heavy  wire  or  metal  band  which  passes  across  the  seat 
of  fracture.  The  piece  is  then  cemented  to  the  teeth  in  the  mouth 
(Fig.  60).  Instead  of  bands  applied  over  the  individual  teeth,  each 
section  of  this  splint  may  be  composed  of  a  single  piece  of  metal 
swaged  over  the  teeth  (Fig.  61). 

A  modification  of  the  foregoing,  useful  in  fractures  where  ap- 
plication of  a  single-piece  splint  is  difificult  or  impossible  is  described 
b}^  Kazanjian^  and  b}^  Hayes.*  The  splint  is  made  in  two  sections 
in  the  same  manner  as  the  preceding,  but  instead   of  being  united 


2In  soldering  these  German  silver  and  copper  bands  and  wires,  for  the  sake  of 
economy  in  military  practice,  tinsmith's  solder  may  be  employed  instead  of  silver 
solder. 

SKazanjian  :      Jour.    Allied  Dental   Societies.    1917,   xii,   27-48. 

4Hayes :      Dental   Cosmos,   October,   1916,    1148. 


120  SURGERY  OF  THE  MOUTH  AND  JAWS. 

by  a  bar  soldered  to  them  prior  to  insertion  in  the  mouth,  each  sec- 
tion is  provided  with  a  heavy  corrugated  wire  or  band  bridging  the 
gap  and  overlapping  its  fellow  of  the  opposite  fragment.  Each  side 
is  cemented  to  the  teeth  separately,  and  the  overlapping  bars  after- 
wards joined  firmly  with  brass  ligature  wire  (Fig.  62).  The  ex- 
tension from  one  side  may  also  be  constructed  to  fit  into  a  slot  ar- 
rangement on  the  other  half,  or  the  two  may  be  attached  together 
with  screws. 

This  double  bridge  arrangement  is  especially  adapted  to  cases  in 
which  it  is  desired  gradually  to  expand  the  gap.  After  each  effort 
at  divulsion,  the  two  pieces  of  the  bridge  can  be  fastened  to  each 
other  in  such  a  way  as  to  maintain  the  amount  of  expansion  gained, 
or  the  continuous  pull  of  a  rubber  band  may  be  employed. 


Fig.  62.  Sectional  metal  jacket  and  wire  splint,  showing  the  bridge  made  of  two 
pieces  of  metal,  the  two  halves  to  be  put  in  separately  and  then  the  two  pieces  of  the 
bridge  bound  together  with  fine  wire. — ^After  Hayes. 


Where  the  bony  defect  is  behind  the  last  available  tooth,  in  order 
to  apply  the  bridge  method  of  maintaining  the  gap,  and  still  allow 
opening  of  the  mouth,  Herpin^  has  described  a  bridge  fastened  to 
the  teeth  anteriorly,  and  on  the  posterior  end  of  the  bridge  is  fastened 
a  vulcanite  saddle  that  embraces  the  anterior  border  of  the  ramus. 

If  necessary,  the  vulcanite  piece  may  be  made  removable,  and 
can  be  provided  with  a  jackscrew  extension  apparatus  so  that  the 
ramus  can  be  gradually  forced  backward  if  forward  dislocation  has 
occurred.    A  similar  appliance  is  also  described  by  Davenport.® 

In  cases  with  displacement  of  lesser  degree,  or  where  for  some 
reason  operative  measures  are  not  to  be  considered,  orthopedic  splints 
for  the  gradual  restoration  of  the  fragments  to  their  normal  position 
may  be  employed.     Great  ingenuity  is  manifested  in  the  adaptation 


SHerpin  :      Gaz.  Hebd.  de  la  Soc.  de  Med.    de  Bordeaux,  1917,   xxxviii,  43-45. 
6Davenport :      Dental   Cosmos,    October,    1916,    1136. 


FRACTURES  OF  THE  LOWER  JAW. 


121 


Fig.    63. 


Fig.    64. 


Figs.   63   and   64.      Sectional   vulcanite    splints   with   jackscrews   for   slow    separation 
of   fragments. — After   Hayes. 


Fig.    65.       Swaged     metal     jacket     splint     with     hooks     and     ligature     wire. — After 
Davenport. 


133 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


of  these  principles  to  individual  cases.     The  forms  of  apparatus  most 
commonly  used  for  this  purpose  are : 

(1)  The  sectional  band  and  wire  splint  described  on  page  118. 

(2)  Sectional  vulcanite  splint  with  jackscrew  (see  Figs.  63  and 
()4.)      The  jackscrew   may  be   replaced   with   a   spring. 

(3)  Lugs  and  inclined  planes. 

In  cases  where  there  is  a  tendency  to  lateral  displacement,  lugs 
or  inclined  planes  may  be  placed  in  splints  in  various  places  to  en- 
gage with  the  opposing  jaw  in  such  a  w^ay  that,  though  normal  move- 
ment of  the  mandible  is  not  materially  interfered  with,  still  the  frag- 
ments tending  to  lateral  displacement  are  held  in  their  proper  posi- 
tion. Such  lugs  are  also  useful  to  hold  the  fragments  apart  to  as- 
sist in  partially  filling  gaps  over  which  defects  in  the  soft  tissues  are 
to  be  closed  by  flap  grafts  (see  Figs.  65  and  66). 


A.  a. 

Fig.    66.      Metal   jacket  splints  with  iucliued   planes. — After  Hayes. 


(4)  Prosthetic  replacement,  wholly  or  in  part,  of  the  lost  bony 
tissue,  with  metal  or  vulcanite  sections  attached  to  the  remaining 
teeth.  These  prostheses  may  carry  teeth,  and  also  act  as  a  basis 
for  plastic  operative  procedures,  whereby  the  soft  tissues  are  ac- 
curately moulded.  The  use  of  such  appliances  is  restricted,  as  a 
rule,  to  cases  where  the  amount  of  bone  lost  precludes  the  prob- 
ability of  new  bone  formation,  though  they  may  be  employed  to  main- 
tain separation  at  the  upper  portion  of  the  gap  with  the  view  to 
regeneration  of  the  lower  border  of  the  bone. 

An  appliance  of  the  tvpe  under  consideration  is  described  by 
Cryer^,   which   was   employed  to   fill   the  gap   remaining  after  resec- 

'i'Cryer :      University   Medical  Magazine,    Pennsylvania,   .Tune,    1900. 


FRACTURES  OF  THE  LOWER  JAW. 


123 


Fig.    67-A. 


Fig.  67.  Sectional  removable  vulcanite  prosthesis  to  replace  symphysis  of  mandible 
and  to  maintain  correct  separation  of  fragment.  Fig.  67-A  shows  sections  separated  and 
metal  jackets  to  be  cemented  to  molar  teeth.  Fig.  67-B  shows  pieces  assembled.  For 
complete  description,  see  text. — After  Cryer. 


124  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tion  of  the  anterior  portion  of  the  mandible  for  osteosarcoma.  The 
resected  portion  of  the  jaw  extended  from  the  first  molar  on  one 
side  to  the  first  molar  on  the  other.  Bands  were  fitted  to  the  lower 
molar  teeth  on  each  side  and  soldered  together  (Fig.'  67,  a  and  b). 
On  the  outer  side  of  each  series  of  bands  was  soldered  a  flattened 
tube  or  slot  (d),  for  the  reception  of  wires  of  the  same  shape  (t) 
which  were  attached  anteriorly  to  a  vulcanite  piece  (v)  shaped  to 
represent  as  nearly  as  possible  the  last  portion  of  bone.  In  order 
that  the  appliance  might  be  removed  when  found  necessary,  either 
during  the  healing  of  the  tissues  or  afterwards  for  cleansing,  altera- 
tion, or  repair  of  the  apparatus,  it  was  made  in  sections,  as  seen  in 
(v  and  v^).  Later  this  temporary  appliance  was  replaced  by  a 
permanent  one  (Fig.  68),  carrying  teeth,  and  made  in  one  piece,  the 


Fig.  68.  Permanent  chin  prosthesis.  This  splint  has  been  frequently  used  in  the 
present  war  and  is  one  of  the  most  practical  methods  of  compensating  partial  loss  of 
the  mandible.  The  temporary  splint  is  usually  made  of  a  block  of  tin  attached  to  a  tin 
gutter  or  jacket  splint  that  fits  loosely  over  the  remaining  teeth  and  alveolar  process. 
The  permanent  splint  is  incorporated  in  a  partial  lower  denture.  In  the  original  Marten 
splint  the  block  was  wired  directly  to  the  bone  ends,  but  this  is  neither  desirable  nor 
necessary. — After   Cryer. 

pillars  (g)  fitting  into  the  holes  (i"),  the  end  of  the  wire  (e)  fitting 
into  the  hole  (ii),  and  the  two  vulcanite  sections  being  bound  to- 
gether by  the  threaded  pillar  (j).    (See  Figs.  67a  and  G7b.) 

Appliances  similar  to  the  above  may  be  made  of  case  tin,  the 
weight  of  the  latter  aiding  greatly  in  retention. 

The  case  shown  in  Fig.  69  is  of  particular  interest  because  of 
the  extreme  malposition  of  the  lower  jaw  and  because  there  had  been 
a  transverse  fracture  of  the  upper  jaw  that  had  healed  by  ligamentous 
union.  After  freeing  the  malunion  of  the  lower  jaw  it  was  wired 
to  the  upper  teeth  by  means  of  dental  splints,  but  the  ligamentous 
union  of  the  upper  jaw  yielded  slightly  to  the  muscular  strain 
exerted  through  the  lower.  When  the  confining  wires  were  removed 
the  maxilla  gradually  returned  to  its  place,  leaving  a  certain  amount 


FRACTURES  OF  THE  LOWER  JAW. 


125 


Fig.  69-A. 


Fig.  69-B. 


Fig  70-A. 


Fig.  70-B. 


Figs.  69  and  70.  Illustrations  emphasizing  the  danger  of  dressing  the  mouth 
open  (Gunning  type  splint)  where  the  fracture  is  behind  the  last  tooth.  In  these 
circumstances  it  is  difficult  to  control  the  ramus  and  as  a  result  the  normal  angle  Is 
liable  to  be  distorted,  leaving  a  permanent  open-bite.  This  is  frequently  a  difficult  con- 
dition to  correct.  Fig.  70-B  shows  the  correction  that  was  obtained  after  sectioning 
the  bone  at  the  sites  of  the  maluiiion  and  cutting  all  binding  sears,  and  the  use  of  inter- 
dental fixation.  The  inability  to  hold  the  jaws  in  proper  relation  by  a  splint  was  due  to 
lack  of  firm  fixation  of  the  upper  jaw  at  the  site  of  the  original  transverse  maxillary 
fracture.  The  use  of  an  elastic  chin  bandage  brought  the  body  of  the  mandible  to  its 
proper   position   and  held   it  there. 


126  SURGERY  OF  THE  MOUTH  AND  JAWS. 

of  malocclusion,  shown  in  Fig.  70,  and  this  in  spite  of  the  use  of  an 
elastic  chin  bandage  in  addition.  This  difficulty  could  not  have 
been  overcome  by  a  Gunning  splint,  because  the  fractures  were  be- 
hind the  last  molars  and  there  would  have  been  no  control  of  the 
posterior  fragment.  A  subsequent  report  from  the  patient  states 
that,  with  the  persistent  nightly  use  of  the  elastic  chin  bandage,  the 
teeth  have  come  up  to  a  good  occlusion. 

In  the  description  of  the  methods  here  given,  no  attempt  has  been 
made  to  include  all  of  the  splints,  or  the  devices  that  have  been  pro- 
posed or  contrived.  They  are  almost  innumerable,  some  of  them  too 
simple  to  be  efficient,  and  others  quite  fantastic  in  their  complexity 
(one  apparatus  described  included  a  corset,  an  intrascapular  pad,  an 
occipital  pad,  a  jury  mast,  a  chain,  and  a  jaw  piece,  while  various 
kinds  of  extension  apparatus  with  weights  and  pulleys,  or  head  pieces, 
are  still  being  presented),  but  most  of  them  are  predecessors,  modifica- 
tions, or  combinations  of  some  one  or  more  of  the  methods  here  de- 
scribed. By  some  one,  or  a  combination  of  several  of  these,  the  frag- 
ments in  almost  every  conceivable  fracture  can  be  held  in  position. 
Wiring  the  lower  to  the  upper  jaw,  either  by  the  teeth  or  by  a  wire 
passed  around  the  lower  jaw  and  fastened  to  the  upper  teeth,  and  when 
necessary,  wiring  the  bones  directly  are  by  far  the  most  common 
plans  of  treatment  that  we  now  resort  to  in  the  treatment  of  frac- 
tures of  the  lower  jaw. 

Care  of  the  Tissues. — Fractures  of  the  body  are  nearly  always 
compound,  the  possible  exceptions  being  fractures  in  jaws  that  are 
without  teeth  at  the  site  of  fracture.  Whether  or  not  an  open  fracture 
of  the  body  will  become  infected  depends  largely  upon  the  amount  of 
injury  to  the  coverings  of  the  bone  and  the  amount  of  separation. 

Fractures  of  the  ramus  or  its  processes  are  usually  not  open  frac- 
tures. In  every  fracture  of  the  body  where  there  has  been  a  distinct 
separating  or  splintering  of  the  fragments,  it  is  a  safe  procedure  to 
drain  externally  by  inserting  a  small  drain  through  a  stab  wound,  that 
will  communicate  with  the  break,  made  under  the  jaw  or  chin.  If  sup- 
puration does  not  supervene,  the  drainage  wound  will  close  without 
leaving  a  noticeable  scar.  If  suppuration  occurs,  the  bone  and  the  soft 
tissues  will  both  be  conserved  by  this  puncture.  This  can  be  done 
with  a  local  anesthetic.    (Fig.  71.) 

This  simple  drainage  procedure  is  of  great  importance  in  simple 
fractures,  lessening  the  swelling  and  suppuration  and  conserving  the 
vitality  of  splinters  in  comminuted  fractures.  In  the  lacerated 
wounds  caused  by  bullets  or  shell  fragments  the  importance  of  free 
drainage  cannot  be  overestimated. 

In  simple  fractures  the  inferior  dental  artery  may  be  torn  across, 


FRACTURES  OF  THE  LOWER  JAW. 


127 


but  the  bleeding-  will  cease  on  adjusting  the  fragments.  No  atten- 
tion is  to  be  paid  to  an  injury  of  the  inferior  dental  nerve.  If 
neuralgia  should  follow,  it  should  be  treated  as  outlined  in  Chap, 
XLIV. 

An  ice  bag  applied  for  a  few  days  over  the  site  of  fracture  so  as  to 
keep  the  skin  cool,  not  cold,  will  limit  the  inflammation  and  usually 
relieve  pain.  (For  the  care  of  accompanying  injuries  of  the  soft  parts, 
see  Chap.  V.)  Except  for  some  special  reason,  no  piece  of  bone 
that  is  still  attached  to  the  soft  tissues  should  be  removed.  The  estab- 
lishment of  drainage  from  below  will  give  an  attached  fragment  a  fair 
chance  to  live  and  unite. 


Pig.  71.  Showing  cliaracteristie  swelling  that  frequently  occurs  and  often  persists 
for  months  after  an  infected  fracture.  This  may  take  place  without  any  evident  sup- 
puration at  the  site  of  fracture.  It  is  prevented  by  immediate  drainage  of  the  fracture 
as  described  on   page    126. 

Reports  from  the  war  zone  give  many  instances  where  a  com- 
plete segment  of  the  jaw  bone  had  apparently  been  destroyed,  yet 
with  free  drainage,  care  of  the  tissues,  and  maintaining  the  gap  by 
a  bridge  splint,  regeneration  of  bone  in  the  defect  had  taken  place. 

In  open  fractures  that  are  seen,  after  suppuration  has  set  in,  free 
external  drainage  should  be  made  from  below,  but  fragments  of  bone 
should  not  be  removed  until  they  have  become  completely  detached. 


128  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Unless   they  are   very   large,   they   will  usually   work   their   way  out 
from  above  or  below. 

It  is  possible  that  a  tooth  of  a  socket  that  is  involved  in  the  frac- 
ture will  sooner  or  later  have  to  be  removed.  Sometimes  in  clean 
cases  it  is  advisable  to  retain  such  a  tooth  for  a  time  to  preserve  the 
continuity  of  the  dental  arch.  If  the  tooth  or  teeth  interfere  with 
approximation,  or  if  the  line  of  fracture  is  evidently  infected,  it  is 
better  to  remove  such  teeth  at  once. 

Care  of  the  Mouth. — While  it  is  desirable  to  apply  splints  at  the 
earHest  possible  moment,  still  the  teeth  should  be  first  cleansed  and 
if  there  are  suppurating  areas  draining  into  the  mouth  these  should 
be  cared  for  either  by  the  use  of  frequently  changed  gauze  packs 
or  by  establishing  inferior  external  drainage.  The  use  of  external 
drainage  is  a  thing  that  to  the  writer's  mind  should  be  more  freely 
employed  than  is  commonly  the  practice. 

The  intraoral  treatment  consists  of  the  following: 

1.  Tincture  of  iodine  is  applied  every  other  day  to  the  gums  and 
teeth  by  means  of  small  pledgets  of  cotton. 

2.  Pledgets  of  cotton  saturated  with  hydrogen  peroxide  are  rubbed 
over  the  teeth  and  all  mucous  surfaces  twice  daily. 

3.  The  mouth  is  irrigated  with  an  antiseptic  fluid  3  or  4  times 
a  day.  This  may  consist  of  a  saturated  solution  of  boric  acid, 
potassium  permanganate,  1-3000,  or  sodium  hypochlorite  solution  in 
the  form  of  Dakin's  fluid  or  chlorazene.  A  convenient  method  is  to 
have  a  glass  irrigating  jar  filled  with  the  fluid  suspended  over  the 
head  of  the  patient,  fitted  with  a  rubber  tube  and  glass  cannula 
through  which  the  mouth  can  be  irrigated  at  frequent  intervals. 

4.  Deposits  of  tartar  are  scaled  from  the  teeth  and  the  surfaces 
polished.  The  mouth  is  gradually  cleared  of  broken  roots  and  frag- 
ments. If  able,  the  patient  is  allowed  to  clean  his  own  teeth  with  a 
brush. 

5.  In  cases  with  excessive  salivation,  the  excess  of  saliva  may  be 
removed  by  means  of  a  hand  saliva  ejector  operated  by  the  patient. 
Rubber  bibs  may  also  be  provided  to  catch  the  dribbling ;  and  if  the 
patient  is  able  to  swallow,  a  dam  of  modeling  composition  can  some- 
times be  made  which  will  stop  the  loss  of  saliva. 

FEEDING  DURING  THE  TREATMENT  OF  A  FRACTURE 

OF  THE  JAW. 

Food  and  fresh  air  are  important  factors  in  the  treatment  of  any 
fracture.  With  a  fracture  of  the  jaw,  especially  if  the  jaws  are  wired 
together,  especial  attention  must  be  paid  to  the  feeding.  With  an 
interdental  splint,  ordinary  soft  foods  and  chopped  meat  can  be  taken 


FRACTURES  OF  THE  LOWER  JAW.  129 

from  the  first.  ^   When  the  jaws  are  wired  together,  the  diet  must  often 
be  restricted  entirely  to  fluids. 

Diet.- — ^A  consideration  of  the  methods  of  administration  and  the 
character  and  variety  of  food  in  individual  cases  is  of  the  utmost 
importance  when  a  patient  has  to  be  on  a  liquid  or  semisolid  diet  for 
weeks.  As  much  variety  as  possible  is  essential  in  order  to  provide 
sufficient  nourishment.  The  patient  on  liquid  diet  loses  weight  at 
first,  but  after  a  time  with  proper  selection  and  variation  he  begins 
to  regain  it.  Not  all  patients  thrive  on  a  purely  albuminous  diet, 
and  it  is  well  to  mix  it  with  liquid  potatoes,  gruels,  and  fruit  juices. 
Especially  in  older  people  highly  albuminous  diet  is  apt  to  cause" 
diarrhea. 

The  methods  of  administering  liquid   food  to  be  resorted  to  ac- 
cording to  the  exigencies  of  the  case  are : 

Sucking  through  a  porcelain   goose-necked    feeder. 
Funnel  with  tube  to  pharynx  through  mouth. 
Tube  to  the  stomach. 
Tube  through  the  nose. 
It  is  surprising  what  can  be  administered  through  a  half-inch  tube 
introduced  into  the  back  of  the  mouth,  even  in  the  way  of  mashed 
potatoes,  minced  meat,  etc. 

Semisolid   Dietary   for    Convalescent   Patients. 
Same  as  above  in  4  hourly  feeds. 
In    addition: 

Baked   custard. 

Strained    fruit    juice    or    stewed    fruit. 
Jelly. 

Benger's  food. 
Bread   and  milk. 
Porridge. 

(per  diem) 

Convalescent   Semisolid. 
Breakfast:    7:45  a.   m. 

Porridge,   1  pint,  milk,  1  pint,  sugar. 
Tea,   thin    bread    and   butter. 
Alternative,  bread  and  milk  or  gruel. 
Luncheon:    11  a.  m. 

Bread   and   milk,   or   beef   tea,   with   bread. 
Dinner:    1  p.  m. 

Minced   meat,  mashed  potatoes,   greens. 
Milk  pudding. 
Tea:    4  p.  m. 

Tea,  or  bread  and  milk;  2  eggs  lightly 

boiled,  poached,  fried,  or  scrambled. 
Bread  and  butter. 
Supper:    7  p.  m. 

Cocoa,  1  pint,  or  bread  and  milk. 


130  SURGERY  OF  THE  MOUTH  AND  JAWS. 

A  No.  18  French  gum  catheter  introduced  low  in  the  esophagus 
through  the  nostril  and  anchored  to  the  lip  with  adhesive  plaster  is 
usually  well  tolerated  for  weeks,  and  through  this  liquids  may  be 
given  through  a  funnel  or  semisolids  may  be  forced  from  a  syringe. 
If  the  catheter  is  placed  too  deep  in  the  esophagus,  fluids  will 
regurgitate  through  the  tube  and  a  clip  on  the  tube  may  be  neces- 
sary. If  the  tube  is  not  sufficiently  far  down,  food  may  regurgitate 
around  the  catheter. 

For  convenience,  the  following  summary  of  dietary,  taken  from 
Kazanjian^,  comprising-  the  range  of  liquid,  semiliquid,  and  semisolid 
diet,  is  given  here. 

Summary  of  Dietary. 

Acute  Injury  of  Jaw. 

Liquid  through  esophageal  tube  or  mouth  tube. 

Every  2  hours   during  day. 

Every  4  hours  during  night. 

Milk,  1  pint,  egg  1,  or  strong  soup,  or  Benger's  food  with  egg;  or 
Bovr'il  made  with  milk,  or  thin  arrowroot  with  Valentine's  meat  juice;  or 
boiled  custard  with  addition  of  stimulants — brandy  or  port  wine  as  ordered. 

Basis  of  dietary  24  hours: 

Milk,  4  pints;   eggs,   4;   soup,   2  pints. ^ 


SKazanjian  :     Journal  of  the  Allied  Dental  Societies,  1917,  xii,  29-48. 

spive  hundred  grams  of  perfectly  fresh  chopped  lean  beef  with  an  equal  quantity 
of  water,  soaked  for  six  hours  at  an  ice-cold  temperature,  will,  when  the  fluid  Is 
pressed  out,  yield  500  cubic  centimeters  of  rich  beef  juice  which  may  be  taKen  raw 
or  put  into  soups.  The  juice  expressed  from  boiled  or  baked  meats  is  much  more 
palatable,  but  not  so  economical.  Of  course,  no  dependence  should  be  placed  upon 
beef  teas  or  clear  soups. 


CHAPTER  IX. 

TREATMENT  OF  INDIVIDUAL  FRACTURES. 

The  tissues  themselves  having  been  cared  for,  the  next  indication 
is  the  restoration  of  the  broken  bone  to  its  normal  outline. 

FRACTURES  WITHOUT  LOSS  OF  SUBSTANCE. 

The  most  common  site  of  a  fracture  is  in  the  neighborhood  of  the 
mental  foramen.  Such  a  fracture  may  be  associated  with  fractures 
in  any  part  of  the  bone,  often  in  a  corresponding  site,  or  just  in  front 
of  the  angle  on  the  opposite  side. 

For  the  treatment  of  most  single  or  double  fractures  in  the  anterior 
part  of  the  body,  a  general  anesthetic  is  not  required.  It  is  not  re- 
quired for  fractures  of  the  angle  where  the  fragments  are  not  held 
rigidly  in  a  false  position.  In  most  cases  where  the  bones  are  to  be 
wired  or  fixed  by  plates,  a  general  anesthetic  is  preferable,  and  in  a 
fracture  near  the  angle  where  the  posterior  end  of  the  body  is  locked 
behind  the  upper  molars  by  a  spasm  of  the  muscles  of  mastication,  a 
general  anesthetic  may  be  indispensable. 

There  is  usually  little  difficulty  in  manipulating  an  anterior  frag- 
ment into  place.  When  in  a  fracture  at  the  angle  the  chin  is  depressed 
and  the  body  is  locked  behind  the  upper  teeth,  the  displacement  can  be 
overcome  by  placing  the  thumb  on  the  occlusal  surface  of  the  molars 
with  the  fingers  underneath  the  jaw  and  depressing  the  posterior  end 
of  the  fragment  as  it  is  drawn  forward. 

In  restoring  the  fractured  arch,  the  occlusion  of  the  teeth  should 
be  the  guide  to  the  position  in  which  the  fragments  are  to  be  placed 
(Figs.  72  and  73).  This  occlusion  can  always  be  determined  by  ob- 
serving the  facets  that  have  been  worn  on  the  occlusal  edges.  When 
there  is  loss  of  bone,  a  new  occlusion  may  have  to  be  established. 

In  fractures  through  the  canine  fossa,  owing  to  the  fact  that  the 
incisor  teeth  are  easily  drawn  from  their  sockets  by  the  constant  up- 
ward pull,  it  is  sometimes  impossible  to  hold  the  mental  fragment  up 
to  occlusion.  Success  is  more  apt  to  follow  if  the  strain  is  distributed 
over  all  of  the  teeth  in  the  mental  fragment,  but  it  may  be  necessary 
to  treat  the  fragment  with  the  mouth  open,  or  to  pass  a  wire  around 
the  body  of  the  bone,  as  described  under  methods   (Figs.  38  and  59). 

To  fix  the  mouth  wide  open  is,  for  a  time,  a  hardship  to  the  pa- 

131 


132 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


tient;  but  an  opening  of  1  or  2  centimeters  is,  as  a  rule,  all  that  is 
needed,  and  this  can  be  maintained  with  no  great  discomfort. 

The  deformity  that  usually  results  from  the  inadequate  treatment 
of  a  fracture  near  the  canine  fossa  is  a  depression  of  the  mental  frag- 
ment of  about  5  millimeters  or  less  at  the  site  of  fracture.  With  a  full 
set  of  teeth,  this  is  a  distinct  deformity,  but  if  there  are  no  teeth,  this 
would  be  hardly  noticed.  A  fracture  exactly  corresponding  to  the 
symphysis  would  be  almost  a  curiosity.  In  fractures  near  the  symphy- 
sis, there  is,  as  a  rule,  little  displacement;  some  sort  of  a  dental 
splint,  usually  a  bar  or  a  wire  fixed  to  two  canine  bands,  is  used. 


Fig.    72. 


Fig.    73. 


These  two  photographs  illustrate  a  case  of  fracture  of  the  lower  jaw  between  the 
premolars  on  the  patient's  left  side,  in  which  the  right  lower  canine  was  placed  behind 
(distal  to)  the  upper  cuspid.  As  a  result,  it  will  be  seen  that  the  teeth  cannot  come 
up  to  proper  occlusion.  When  the  teeth  are  brought  into  proper  occlusion,  it  is  usually 
very  easy  to  hold  them  there,  but  it  is  often  difficult  to  prevent  further  displacement 
when  the  natural  occlusion  is  not  established.  These  photographs  are  presented  to  em- 
phasize the  necessity  of  reestablishing  the  natural  occlusion  wherever  possible.  No  den- 
tist would  ever  make  such  a  mistake,  but  it  is  one  into  which  a  surgeon  may  easily  fall. 


For  a  fracture  occurring  anywhere  behind  the  last  tooth,  man- 
dibular splints,  except  of  the  type  described  by  Herpin  (Fig.  75), 
are,  of  course,  of  no  use.  Here  the  body  of  the  mandible  is 
best  held  in  place  by  wiring  it  to  the  upper  jaw,  and  the  treatment  of 
the  posterior  fragment  will  depend  upon  the  direction  and  character  of 
the  break.  If  the  line  of  fracture  is  transverse  from  within  outward, 
the  posterior  fragment  will  require  no  special  attention ;  but  if  the  frac- 
ture is  oblique,  then,  if  the  periosteum  is  torn,  there  may  be  a  forward, 


TREATMENT  OF  INDIVIDUAL  FRACTURES.  133 

an  upward,  and  an  inward  or  outward  displacement  of  the  lower  end  of 
the  posterior  fragment   (Fig.  74). 

This    forward   displacement   of   the   ramus   may   be   controlled   by 
first  replacing  the  ramus  and  then  putting  a  piece  of  softened  model- 


Fig.   74.      X-ray  showing  tilting  forward  of  tlie  ramus  in  an  oblique  fracture  of  the 
body  just  In  front  of  the  angle. 


Fig.   75.      Lower  bar  and  saddle  splint. — After  Herpin. 


ing  composition  between  the  last  teeth  and  the  anterior  border  of  the 
ramus  after  leaving  fixed  the  lower  to  the  upper  jaw,  or  by  direct 
fixation  of  the  bone  fragments  or  by  the  splint  shown  in  Fig.  75 
(Herpin). 


134  SURGERY  OF  THE  MOUTH  AND  JAWS. 

In  fractures  of  the  ramus  situated  within  the  attachment  of  the 
masseter  and  internal  pterygoid  muscles,  there  is  rarely  a  lateral  dis- 
placement. All  that  is  needed  is  to  give  rest  by  fixing  the  lower  to  the 
upper  jaw. 

Fractures  of  the  coronoid  process  are  the  rarest  of  all  and  are 
usually  associated  with  a  fracture  of  the  neck  of  the  condyle.  Such  a 
fracture  of  itself  would  require  but  little  treatment  except  fixation  of 
the  lower  jaw  for  the  control  of  the  pain.  If  such  a  fragment  were 
to  later  interfere  with  proper  movement  of  the  jaw  by  becoming  at- 
tached to  a  fractured  condyle,  the  coronoid  could  be  removed. 


Fig.  76.  X-ray  showing  a  case  in  which  there  was  a  considerable  loss  of  bone  be- 
hind the  first  molar,  and  in  which  the  ramus  has  tilted  forward  until  the  ends  of  the 
bone  are  in  contact. 

When  symptoms  are  present,  a  fracture  of  the  neck  of  the  condyle 
should  be  treated  by  fixing  the  lower  to  the  upper  jaw.  If  the  condyle 
is  drawn  forward  by  the  pull  of  the  external  pterygoid  muscle,  the 
displacement  cannot  be  corrected,  but  the  larger  controllable  fragment, 
the  whole  of  the  remaining  part  of  the  jaw,  can  be  brought  forward 
to  a  corresponding  position.  This  is  done  by  fastening  an  inferior 
molar  to  a  tooth  above  and  in  front  of  it — as  the  first  lower  molar  to 
the  first  upper  bicusped.  The  correct  position  could  be  determined  by 
an  x-ray  examination.     The  condyle  may  have  to  be  removed.     (vSee 


TREATMENT  OF  INDIVIDUAL  FRACTURES.  135 

Ivy,  Trans.   Philadelphia  Academy  of   Surgery,  Annals   of   Surgery, 
1915,  Ixi,  502-506.) 

TREATMENT  OF  FRACTURES  COMPLICATED  BY  LOSS 

OF  BONE. 

Fractures  in  which  there  is  considerable  bone  missing  will  have  to 
be  treated  according  to  their  location  and  the  amount  of  bone  lost.  Un- 
less the  loss  involves  the  full  width  of  the  body,  these  do  not  present 
any  especial  difficulty;  for,  as  long  as  there  are  even  small  pieces  of 
nourished  bone  in  contact,  these  will  unite,  and  sufficient  bone  usually 
fills  in  around  them.  However,  until  a  strong  union  occurs,  the  weak 
place  should  be  protected  from  any  strain  that  would  cause  a  refrac- 
ture.  If  there  are  teeth  on  both  sides  of  the  weak  place,  this  can  be 
done  by  adjusting  a  dental  splint.  If  the  complete  loss  of  substance 
is  not  greater  than  1  centimeter,  and  is  situated  behind  the  bicuspids, 
by  removing  all  teeth  from  the  posterior  fragment,  the  latter  can  be 
made  to  tilt  forward  until  it  is  in  contact  with  the  anterior  fragment 
(Fig.  76).  In  treating  such  a  case,  the  anterior  fragment  must  be  held 
fixed  in  its  proper  place  until  a  firm  bony  union  is  obtained ;  otherwise 
it  will  be  pulled  around  to  meet  the  posterior  fragment. 
Larger  gaps  in  the  lateral  part  of  the  body  may  be  reme- 
died by  resecting  the  ramus  and  carrying  forward  the  posterior  part  of 
the  body.  Gaps  in  the  anterior  part  of  the  bone  may  be  filled  ac- 
cording to  plans  given  in  Chap.  XIX.  Loss  of  substance  in  one 
ramus  will  not  cause  noticeable  deformity  or  serious  interference  with 
function. 

TIME  REQUIRED  FOR  UNION. 

This  depends  upon  the  character  of  the  fracture,  the  number  of 
fractures,  and  the  reparative  effort  of  the  individual.  In  single 
fractures,  where  there  is  little  suppuration  and  no  appreciable  loss  of 
bone,  fairly  good  union  usually  occurs  in  three  weeks.  This  will  not 
be  strong  bony  union,  but  will  be  sufficient  to  prevent  pain  or  displace- 
ment, and  with  ordinary  care  will  go  on  to  completion  without  the  aid 
of  splints.  While  a  double  fracture  should  unite  as  quickly  as  a  single 
fracture,  there  is  more  tendency  to  displacement,  and  greater  firmness 
is  necessary  before  the  splints  can  be  dispensed  with.  Such  fractures 
should  be  kept  fixed  for  at  least  five  weeks.  Suppurating  open  frac- 
tures and  fractures  in  which  there  is  considerable  loss  of  bone  will  re- 
quire longer  fixation.  A  weak  union  of  an  interdental  fracture,  single 
or  double,  can  be  advantageously  braced  with  a  dental  splint. 


136  SURGERY  OF  THE  MOUTH  AND  JAWS. 

DELAYED  UNION. 

Union  may  be  retarded  by  lack  of  approximation  or  by  lack  of  fixa- 
tion of  the  fragments,  by  the  interposition  of  detached  bone  fragments, 
teeth,  or  a  foreign  body,  by  local  infection,  and  by  some  fault  in 
the  vital   reparative   effort. 

Syphilis,  tuberculosis,  pregnancy,  or  any  general  depression  may  be 
responsible  for  delayed  union,  but,  at  times,  no  cause  can  be  found. 
Besides  specific  and  tonic  treatment,  the  administration  of  the  extract 
of  thyroid  glands  is  supposed  sometimes  to  influence  union  favorably. 
Besides  general  treatment,  the  alignment  should  be  preserved  by  ap- 
propriate splints,  and  the  ends  of  the  bone  may  be  irritated  aseptically 
with  an  awl.  Dr.  Gilmer  suggests  that  a  coarse  file  be  used  for  this 
purpose.  As  soon  as  a  fibrous  union  that  preserves  the  alignment 
is  formed,  splints  may  be  dispensed  with,  as  some  movement  often 
stimulates  union.  Non-union  is  rare.  A  genuine  non-union  might, 
after  all  constitutional  remedies  have  failed,  be  treated  by  resection 
and  wiring,  or  by  a  splint  graft.  Several  months'  trial  should  be 
given  to  simpler  means  before  this  is  resorted  to.  In  doing  the 
former,  the  least  possible  amount  of  bone  should  be  removed  from 
the  ends  of  fragments. 

MALUNION. 

Malunion  is  rarely  sufficiently  pronounced  to  warrant  interfer- 
ence, but  severe  deformities  with  bony  union  should  be  treated  as 
outlined  in  Chap.  XXI.  When  the  union  is  partial,  they  may  be 
treated  by  orthopedic  splints  and  cutting  of  bands  as  shown  in  Chap. 
XXI. 

GUNSHOT  FRACTURES  OF  THE  JAW  BONES. 

Although  the  essential  principles  involved  are  the  same  in  all 
fractures,  yet  owing  to  extensive  shattering  and  loss  of  substance 
of  bone  and  laceration  of  the  soft  parts,  gunshot  fractures  of  the  jaws 
require  separate  consideration.  The  complications  of  loss  of  sub- 
stance of  the  bone,  projection  of  teeth  and  bony  fragments  into  the 
soft  tissues,  extensive  laceration  of  the  soft  tissues  with  wounds  of 
entrance  and  exit,  presence  of  infection,  shock,  etc.,  render  neces- 
sary the  consideration  together  of  all  fractures  involved  in  gunshot 
injuries  of  the  jaws  and  face  ratlier  than  (jf  the  fracture  alone. 

It  is  important  to  determine,  as  far  as  possible,  the  exact  location 
of  tlie  fracture,  the  extent  (jf  comminution  of  the  bone,  the  amount 
of  injur\-  to  tlic  soft  tissues,  and  tlic  presence  of  foreign  bodies,  such 
as  bullets,  pieces  of  clothing,  displaced  teeth,  and  bone  splinters. 

The  displacements  of  the  fragments  in  gunshot   fractures  of  the 


TREATMENT  OF  INDIVIDUAL  FRACTURES.  137 

lower  jaw  are  -in  general  the  same  as  those  found  in  ordinary  frac- 
tures, except  that  they  are  apt  to  be  greater  owing  to  increased 
mobility  from  loss  of  substance. 

From  want  of  early  treatment,  cases  are  often  received  in  base 
hospitals  with  marked  deformity,  the  wounds  septic  and  inflamed. 
If  the  injury  is  in  the  region  of  the  symphysis,  with  part  of  the  chin 
carried  away,  the  two  halves  of  the  mandible  are  apt  to  fall  to- 
gether toward  the  median  line,  narrowing  the  arch.  In  lateral  frac- 
tures, the  larger  fragment  is  drawn  over  to  the  affected  side.  The 
longer  these  displacements  are  allowed  to  continue,  the  greater  the 
difficulty  experienced  in  reduction.  In  the  treatment  of  gunshot  frac- 
tures, practically  all  European  workers  are  agreed  that  the  chief  aim 
should  be  the  reestablishment,  as  soon  as  possible,  of  the  normal 
occlusion  of  the  remaining  teeth  of  the  two  jaws.  This  principle 
should  be  begun  at  the  front,  in  the  evacuation  hospital  where  the 
treatment  given  should  be  part  of  a  general  plan  to  be  followed 
throughout.  In  formulating  a  general  outline  of  treatment  of  these 
cases,  we  are  indebted  to  the  writings  of  Kazanjian,  Colyer,  Herpin, 
Hayes,  Pont,  and  others   (see  bibliography). 

At  the  evacuation  hospital,  which  is  the  first  point  at  which  the 
wounded  man  can  receive  special  attention,  the  parts  must  be  cleansed 
as  far  as  possible,  the  hemorrhage  arrested,  loose  and  broken  teeth 
extracted,  and  the  bony  fragments  approximated  and  temporarily 
fixed  in  as  nearly  a  correct  position  as  possible.  It  is  particularly  es- 
sential at  this  time  that  no  loose  fragments  of  bone  be.  removed  from 
the  site  of  fracture,  as  in  many  cases  pieces  of  bone  apparently  hope- 
lessly injured  will  recover  their  vitality  and  serve  as  a  valuable  matrix 
for  repair. 

The  wounded  parts  should  be  freely  swabbed  with  tincture  of 
iodine. 

Several  methods  of  temporary  fixation  are  available,  according  to 
the  needs  of  individual  cases,  as  follows : 

Fixation  in  Fracture  of  the  Lower  Jaw. — 

(a)  If  the  upper  jaw  is  more  or  less  intact,  a  roll  of  softened 
modeling  composition  is  placed  between  the  teeth,  and  the  upper 
and  lower  teeth  brought  into  as  nearly  correct  occlusion  as  possible, 
the  composition  being  allowed  to  harden  in  position.  Additional 
stability  is  afforded  by  a  chin  cup  of  modeling  composition  held  in 
place  by  an  elastic  head  bandage,  which  should  not  be  applied  tightly. 

(b)  If  the  breathing  space  through  the  nose  is  clear,  the  Dorrance 
or  the  Supplee  stock  splint  described  on  page  ll-L  may  be  used  to 
hold  the  fragments  temporarily  in  approximate  position. 


138  SimOERY  OF  THE  MOUTH  AND  JAWS. 

(c)  Pickerill's  modification  of  the  Kingsley  splint  (see  page  115) 
has  the  advantage  that  the  mouth  may  be  opened. 

(d)  Intermaxillary  fixation  by  direct  application  of  wire  ligatures 
to  teeth  of  the  upper  and  lower  jaws  is  often  of  value  as  a  tem- 
porary or  permanent  measure.      (See  description  on  page  101.) 

Fixation  in  Fracture  of  the  Upper  Jaw. — In  fracture  of  the 
upper  jaw,  to  prevent  displacement,  the  metal  Gunning  splint  may 
be  applied  with  a  bandage  under  the  jaw,  or  the  Pickerill  spHnt  re- 
versed and  attached  to  a  head  cap  may  be  used. 

After  the  bones  have  been  approximated,  the  overlying  soft  parts 
may  be  brought  loosely  together  over  them,  special  provision  being 
made  for  drainage.  Care  should  be  taken  not  to  suture  the  soft  tis- 
sues so  tightly  as  to  maintain  malposition  of  the  bones  and  to  inter- 
fere with  later  correction. 

If  there  is  any  doubt  as  to  the  efficiency  of  the  drainage,  it  is 
better  to  pack  the  wounds,  keeping  them  well  open.  In  the  applica- 
tion of  bandages  also,  where  there  has  been  extensive  comminution  of 
the  bones  of  the  nasal  and  upper  jaw  regions,  the  bandage  should  not 
make  pressure  over  these  parts. 

The  swelling  of  the  tongue  and  other  soft  tissues  as  well  as  nasal 
obstruction  often  renders  breathing  difficult  in  these  cases.  Owing 
to  the  high  mortality  following  it,  tracheotomy  should  be  avoided 
if  possible  to  ensure  a  sufficient  amount  of  air  by  any  other  means. 
Drawing  the  tongue  forward  and  maintaining  it  in  this  position  by 
a  thread  attached  to  the  chin  with  adhesive  plaster,  or  the  insertion 
of  rubber  tubing  through  the  mouth  and  passed  well  back  into  the 
pharnyx  will  in  many  cases  allow  of  adequate  respiration. 

By  careful  attention  to  the  above  mentioned  details,  the  patient 
will  arrive  at  the  base  hospital  in  much  better  condition,  and  his 
period  of  treatment  may  be  consequently  lessened  by  several  months. 

General  Treatment  at  Base  Hospital. — On  arrival  at  the  base 
hospital  usually  in  from  two  to  four  days  after  receipt  of  the  wound, 
the  presence  of  dangerous  illness  must  be  the  first  consideration. 
The  wounds  are  always  septic,  and  the  patients  show  weakness  and 
fatigue. 

The  patient  is  put  to  bed,  and  measures  to  combat  shock,  etc., 
are  instituted.  Free  drainage  is  provided  for  external  wounds,  and 
dressings  are  applied  in  the  form  of  hot  fomentations.  Until  the 
patient  is  in  better  general  condition  no  attempt  is  made  to  suture 
the  soft  parts,  improve  the  alignment  of  the  bones,  or  perform  any 
operation  except  in  case  of  necessity  to  save  life.  Hypnotics  are 
given  for  pain.  The  use  of  morphine  is  to  be  avoided  as  far  as  possible 
owing  to   the  possibility   of  abolishing  the   laryngeal    reflex   and   the 


TREATMENT  OF  INDIVIDUAL  FRACTURES.  139 

predisposition  tp  aspiration  pneumonia.  Care  of  the  mouth  is  in- 
stituted as  outlined  on  page  128.  Careful  attention  is  given  to  the 
diet,  the  general  principles  of  which  are  found  on  page  129.  The 
treatment  of  acute  cellulitis  and  infection  of  the  floor  of  the  mouth 
and  neck  is  given  in  Chap.  XXVIII. 

Complications. — Complications  which  most  often  lead  to  serious 
consequences  and  sometimes  result  fatally  are : 

1.  Secondary  Hemorrhage. — This  is  due  to  sloughing  of  arterial 
walls  from  infection.  The  arteries  commonly  involved  in  jaw  in- 
injuries  are  branches  of  the  external  carotid,  such  as  the  facial, 
lingual,  and  internal  maxillary.  The  hemorrhage  generally  comes  on 
very  suddenly  and  requires  great  vigilance  on  the  part  of  the  at- 
tendant. It  is  best  controlled  by  double  ligation  of  the  branches  in- 
volved or  even  of  the  external  carotid.  Less  serious  cases  of 
hemorrhage  in  the  mouth  may  be  controlled  by  packing. 

2.  Pneumonia. — This  may  be  due  to  the  septic  condition  of  the 
mouth,  or  may  be  brought  on  by  the  administration  of  a  general 
anesthetic  before  attention  is  given  to  cleansing  the  mouth  wound,  or 
paralysis  of  laryngeal  reflex  with  morphine. 

The  tendency  to  bronchitis  and  broncho-pneumonia  may  be  com- 
batted  to  some  extent  by  keeping  the  patient  in  the  sitting  position 
as  far  as  possible. 

3.  Meningitis,  etc. — Extensive  injuries  of  the  upper  jaw  may 
involve  the  bones  at  the  base  of  the  skull  and  lead  to  meningitis, 
and  other  cerebral  complications. 

In  all  of  these  cases,  hexamethylenamine  may  be  administered  as 
a  precautionary  measure. 

During  the  interval  between  admission  to  the  hospital  and  the 
application  of  any  fixation  apparatus  to  the  jaw  bones,  roentgeno- 
logical examinations  should  be  made  to  obtain  an  accurate  idea  of 
the  extent  and  location  of  the  fractures,  the  involvement  of  the  teeth 
in  the  fracture,  displacement  of  teeth,  presence  of  missiles,  etc. 
When  all  of  the  foregoing  considerations  have  received  attention, 
necessary  steps  must  be  taken  to  obtain  proper  reduction  and 
fixation  of  the  fragments.  This  will  have  been  rendered  much 
easier  if  the  patient  has  received  proper  preliminary  care  shortly 
after  receipt  of  the  injury.  Certain  forms  of  apparatus  can  be  ap- 
plied without  the  preparation  of  casts  of  the  mouth,  while  others 
require  the  preliminary  taking  of  impressions  from  which  casts  or 
models  are  made.  In  many  cases  operative  procedures  are  necessary, 
under  general  anesthesia,  before  the  application  of  splints,  to  bring 
the  fragments  into  good  position,  and  to  remove  foreign  bodies, 
misplaced  splinters  of  bone,  and  teeth.     As  a  general  rule,  little  or 


140 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


no  loose  bone  should  be  disturbed,  as  it  forms  a  matrix  for  repair 
of  spaces  between  the  fragments,  large  gaps  often  being  filled  in 
this  manner.  Teeth  adjoining  the  lines  of  fracture  should  be  ex- 
tracted, otherwise  they  become  sources  of  continued  irritation, 
secondary  abscess  and  sinus  formation.  The  value  of  local  infiltra- 
tion and  nerve  blocking  anesthesia  cannot  be  overestimated  for  curet- 
ting wounds,  removing  teeth  and  loose  sequestra,  opening  abscesses, 
cutting  adhesions,  reducing  displacements,  and  suturing  soft  tissues. 

Plastic  Operations. — In  the  early  days  of  the  war,  where  ex- 
tensive separation  of  the  skin  and  soft  tissues  of  the  face  accom- 
panied fractures  of  the  jaw  bones  with  loss  of  substance,  the  in- 
clination   was    toward   immediate    closure   of    the    facial    wounds    by 


FiK  77  A  series  of  vulcanite  plates  is  m,ade  to  fit  accurately  over  the  forehead 
and  face  in  front  of  the  ears,  and  connected  together  with  screws.  This  serves  as  a  basis 
for    different    attachments.  ,  .  ,  ^-   -^^       a   v.^,  ^  v.„^vic 

The  headgear  is  made  of  straps,  1  inch  in  width,  which  are  tightened  by  a  buckle. 
A  U-shaped  bar  (German  silver  No.  12  American  gauge)  extends  between  the  two  endb 
of  the  vulcanite,  at  the  approximate  level  of  the  upper  lip.  This  bar  S'^^s  add  tional 
rigidity  to  the  appliances  and  also  is  a  basis  of  such  additions  as  ^'■t.'fi^'>'^l  ""^^rils  and 
palatal   supports.      It   is  controlled   and  held   in   place  by   a  hook   or  wire  near   its   socket 

""  ^^^MoVabl'^"  extensions  are  made  of  wire  (German  silver  No.  14  American  gauge)  with 
vulcanite  rubber  pads,  which  can  be  bent  according  to  the  direction  of  P':^^^.^^,.'^^^^  [^f; 
to  relieve  the  tension  of  sutures.      Thoy  arc  hHd   In  place  by  ligatures.— Alter  Ka/an,iian. 

suture,  httle  or  no  consideration  being  given  to  early  correction  of 
the  bony  displacement.  As  a  consequence,  the  cases  finally  came 
into  the  hands  of  the  oral  and  dental  surgeon  with  the  soft  tissues 


TREATMENT  OF  INDIVIDUAL  FRACTURES.  141 

tensely  united  .over  the  deformed  bones,  and  the  difficulties  to  be 
overcome  in  correction  were  enormously  increased.  It  has  now  be- 
come a  well  recognized  principle  that  "no  attempt  should  be  made 
to  suture  the  soft  parts  with  the  idea  of  closing  a  gap  until  such 
time  as  union  of  the  fractured  parts  in  correct  relation  is  well  under 
way  and  permanent  splints  are  adjusted"  (Kazanjian).  By  keep- 
ing the  mouth  cleaned  and  reducing  displacement,  there  will  be  less 
disfigurement  to  rectify.  It  is  not  desirable  to  wait  until  scar  tis- 
.sue  has  formed. 

We  would  amplify  this  to  the  extent  of  saying  that  repair  may 
be  made  over  a  defect  if  the  bony  gap  is  filled  by  a  properly  fitting 
lug  (Marten's  splint)   affixed  to  the  retaining  splint. 

As  soon  as  the  splints  are  adjusted  and  healthy  granulation  of 
the   wounds   has   begun,   the  parts   may  be   sutured.     Kazanjian   de- 


Fig.  78.  Illustrating  method  of  support  by  means  of  revised  Kingsley  splint  with 
wires  and  vulcanite  plate.  Patient  had  an  extensive  clean  wound  due  to  a  shell  fragment, 
severing  the  nose  and  cheeks,  which  were  turned  downward.  (See  Fig.  13.)  Parts  were 
also  supported  in  approximately  normal  position  by  means  of  the  vulcanite  pad. — After 
Hayes. 

scribes  the  use  of  facial  supports  in  these  cases  as  follows :  "Facial 
supports  are  of  great  assistance  in  moulding  the  parts  and  support- 
ing the  sutures.  A  simple  support  is  made  in  the  following  manner : 
ordinary  hooks  are  sewed  close  together  to  the  edge  of  strong  band- 
age material.  A  piece  of  this  is  stuck  to  the  face,  with  collodion 
on  either  side  of  the  sutured  portion  of  the  soft  tissue  and  the  two 
laced  together  with  silk.  Hooks  may  also  be  sewed  to  adhesive  tape. 
Another  form  of  facial  support  is  one  in  which  a  series  of  plates  of 
vulcanized  rubber  held  in  place  about  the  face  and  cheeks  by  head 
gear  serves  as  a  base.     To  this  are  attached  heavy  wires,  with  vul- 


142  SURGERY  OF  THE  MOUTH  AND  JAWS. 

canite  fingers  on  the  ends  to  press  the  tissues  at  certain  places  and 
offset  muscular  tension.  There  are  many  possibilities  for  additions 
and  variations  such  as  tubes  to  serve  as  nostrils,  etc."  (See  Figs.  77 
and  78.) 

Methods  of  Fixation. — Immobilization  of  the  bones  can  usually 
be  carried  out  within  a  few  days  at  a  time  when  the  fractured  parts 
can  still  be  moved  freely.  The  former  occlusion  of  the  lower  teeth 
with  the  upper  should  always  be  the  guide  in  fixation  of  the  frag- 
ments, even  though  this  entails  considerable  separation  between  the 
fractured  ends. 

The  form  of  fixation  to  be  appHed  depends  upon  the  location  of 
the  fracture,  the  amount  of  substance  lost,  the  amount  of  displace- 
ment, the  number,  condition,  and  position  of  teeth  present.  Below 
is  given  a  rational  classification  of  gunshot  fractures  of  the  jaws, 
with  an  indication  of  the  form  of  apparatus  best  adapted  to  each 
form. 

The  selection  and  adaptation  of  the  best  method  of  fixation  for 
individual  cases  must  be  left  to  the  ingenuity  of  the  surgeon  and 
his  assistants.  In  a  general  way,  any  method  of  fixation  that  is 
effective  and  allows  the  mouth  to  be  open,  is  better  than  one  in 
which  the  jaws  must  be  kept  closed.  The  latter  interferes  with 
mastication,  leading  to  ankylosis,  and  hinders  drainage. 

A.     Recent  Fractures. — 

1.  Fracture;  oi?  the;  Bodiy  of  the;  Mandibi.^  Anterior  to  the 
Last  Existing  Tooth  Without  Loss  of  Substance. — Fractures  of 
this  type  frequently  occur  from  concussion,  where  the  projectile  does 
not  strike  the  jaw  itself.  They  may  be  treated  by  methods  of  fixa- 
tion employed  in  civil  practice,  among  the  best  of  which  are  the 
vulcanite  or  metal  jacket  splint  described  on  page  116  (Hullihan's 
splint,  Fig.  57.)  Gilmer's  lingual  band  splint  described  on  page  IIG 
(Fig.  58)  may  also  be  found  useful. 

2.  Fractures  of  the  Body  of  the  Mandibee  Anterior  to  the 
Last  Existing  Tooth  With  Few  Teeth,  Considerabee  DispeacEp 
MENT,  or  Loss  of  Substance. — In  this  class  are  found  the  major- 
ity of  gunshot  fractures.  When  there  is  loss  of  substance  at  the 
symphysis,  the  fragments  tend  to  be  drawn  together  in  front  with 
the  occlusal  surfaces  of  the  teeth  facing  inwards  toward  each  other. 
In  the  lateral  portion  of  the  bone,  the  loss  of  substance  causes  the 
fragment  on  the  sound  side  to  be  drawn  over  to  the  affected  side. 
The  best  method  of  maintaining  separation  and  fixing  the  fragments 
in  their  normal  positions  in  relation  to  the  upper  teeth  in  these  cases 
is  by  the  metal  band  and  wire  splint  described  on  page  120  either 


TREATMENT  OF  INDIVIDUAL  FRACTURES.  143 

made  in  one  aolid  piece  or  applied  in  sections,  afterwards  fastened 
together. 

In  cases  with  considerable  loss  of  substance,  where  there  is  a 
tendency  for  the  lower  jaw  to  swing  over  to  one  side,  the  outer  sur- 
face of  the  spHnt  on  the  opposite  side  may  be  provided  with  a  metal- 
lic flange  to  engage  the  teeth  of  the  upper  jaw,  thus  acting  as  an 
inclined  plane  to  bring  the  teeth  into  proper  occlusion  when  the 
jaws  are  closed    (see  page  123). 

3.  Fracture  oi^  thk  Mandibli:  Behind  the  L'ast  Existing 
Tooth. — The  form  of  apparatus  is  selected  to  best  suit  the  individual 
case.  These  cases  comprise  fractures  of  the  body  of  the  bone,  ramus, 
or  condyle,  with  or  without  loss  of  substance.  Where  there  is  no 
tendency  to  displacement  and  no  loss  of  substance,  the  simplest  form 
of  treatment  is  by  fixation  of  the  lower  jaw  to  the  upper  by  means 
of  ligature  wires  directly  applied  to  the  teeth  (see  page  101)  or 
through  the  intervention  of  Gilmer's  arch  (page  116). 

In  fracture  of  the  angle  and  ramus  with  loss  of  substance,  if 
the  ramus  stays  in  good  position  this  form  of  wiring  may  be  sufficient, 
but  if  the  ramus  displaces  forward  or  laterally,  after  fixing  the 
anterior  fragment  by  wiring  the  teeth  to  those  of  the  upper  jaw, 
the  ramus  may  be  steadied  in  position  by  drawing  it  back  with  a 
hook  passed  around  it  through  the  cheek,  or  a  lion-jaw  forcep  catch- 
ing it  through  the  skin,  and  then  placing  modeling  composition  be- 
tween the  ramus  and  the  last  molars  above  and  extending  down  be- 
hind the  molars  below. 

In  case  the  upper  and  lower  teeth  are  not  available  for  ligating 
with  wire,  intermaxillary  fixation  with  ligature  wire  may  be  carried 
out'  as  follows  :^  Holes  are  drilled  through  the  jaws  at  the  level  of 
the  roots  of  the  teeth  about  three-fourths  of  an  inch  away  from  each 
fracture  line.  Stout  silver  wire  is  then  passed  through  the  holes, 
and  the  fragments  approximated  if  possible.  Further  holes  are 
drilled  in  the  region  of  the  lateral  incisors  in  both  upper  and  lower 
jaws,  or  in  other  suitable  positions,  according  to  the  site  of  the  frac- 
ture, and  silver  wire  passed  through  both.  The  mandible  is  brought 
into  the  desired  position,  and  the  wire  tightened  by  twisting. 

Fractures  in  this  region  may  also  be  treated  through  the  medium 
of  the  upper  and  lower  swaged  metal  jackets  described  on  page  121. 

Occasionally,  also  in  cases  where  there  is  tendency  of  displace- 
ment of  the  jaw  to  one  side,  the  hooks  on  the  splint  afiford  attach- 
ment for  intermaxillary  elastics,  this  force  being  used  to  overcome 
the  deviation. 

Where  it  is  desirable  to  dress  the  jaw  with  the  mouth  open,  and 


iPickerill,  Dominion  Dental  Journal,  1917,  xxix,  217. 


144  SURGERY  OF  THE  MOUTH  AND  JAWS. 

prevent  forward  displacement  of  the  ramus,  the  splint  described  by 
Herpin  (Fig.  75)  is  applicable. 

4.  Gunshot  Fractures  of  thij.  Upper  Jaw. — 

(a)  Partial  fractures  as  a  rule  are  easily  maintained  in  position 
by  some  form  of  appliance  such  as  a  band  and  wire  splint,  or  a 
swaged  metal  jacket  attached  to  the  upper  teeth.  In  unilateral  frac- 
tures, ligation  of  the  teeth  of  the  sound  side  to  those  of  the  lower 
jaw  is  often  efficient. 

(b)  In  transz'erse  fracture  of  the  entire  maxilla,  the  reversed 
Kingsley  bar  splint  combined  with  a  head  cap  as  described  by  Mar- 
shall  (see  page  90)   is  suitable. 

(c)  In  comminuted  fractures  or  those  associated  with  much  loss 
of  bone,  the  modification  of  the  Kingsley  splint  is  not  applicable  as 


Fig.  79.  Modified  Barton  bandage  for  fracture  of  mandible  and  supporting  sub- 
maxillary dressings,  which  avoids  backward  pull  on  chin.  Turns  are  as  follows:  Vertex 
to  chin,  under  chin  to  occiput,  to  vertex,  to  chin,  under  chin,  to  occiput,  to  vertex,   etc. 

pointed  out  on  page  91,  and  the  apparatus  described  and  illustrated 
on  page  92  should  be  employed. 

B.  Old  Fractures  of  the  Mandible  with  Partial  or  Non-union, 
and  the  Fragments  in  Bad  Position. — 

1.  Operative  Treatment. — The  method  of  choice  in  these  cases 
is,  under  local  or  general  anesthesia,  to  divide  adhesions,  fibrous 
bands  or  callus,  bringing  the  fragments  into  their  correct  relations, 
and  fixing  them  there  by  means  of  any  of  the  appliances  described  in 
the  previous  section  suitable  for  the  given  case  in  hand.  Consider- 
able gaps  in  the  bone,  even  amounting  to  several  centimeters  in 
width,  produced  by  this  readjustment  of  the  fragments,  may  be  in 
time  solidly  filled  with  new   bone.     If   non-union  persists  after  sev- 


TREATMENT  OF  INDIVIDUAL  FRACTURES.  145 

eral  months'  trial,  the  case  may  be  considered  suitable  for  replace- 
ment of  the  lost  tissue  by  bone  or  cartilage  grafting.  It  is  in  these 
late  cases  especially  that  the  inclined  planes  made  by  flanges  of  suit- 
able shape  to  engage  the  teeth  of  the  opposite  jaw,  are  of  especial 
value  in  overcoming  the  tendency  to  return  of  the  fragments  to 
their  old  incorrect  position.  In  operating  upon  these  cases,  after 
dividing  cicatrices,  the  separated  tissues  may  be  kept  apart  by  means 
of  softened  modeling  composition  pressed  into  the  wound. 

2.  Orthopedic  Splints. — In.  cases  of  displacement  of  lesser  de- 
gree, or  where  for  some  reason  operative  measures  are  not  to  be 
considered,  orthopedic  splints  for  the  gradual  restoration  of  the  frag- 
ments to  their  normal  position  may  be  employed.  Great  ingenuity 
is  manifested  in  the  adaptation  of  these  principles  to  individual  cases. 
The  forms  of  apparatus  most  commonly  used  for  this  purpose  are : 
the  sectional  band  and  wire  splint,  the  jackscrew,  and  lugs  and  in- 
clined planes,  described  on  pages  121  and  122. 

Bandaging. — Bandaging  in  connection  with  fractures  is  of  im- 
portance. The  most  useful  bandage  is  a  modification  of  the  Barton, 
which  avoids  the  disadvantage  of  the  latter  in  making  backward 
pressure  on  the  chin  (Fig.  79). 

An  elastic  bandage,  preferably  a  piece  of  rubber  dam  15  or  17 
cm.  broad,  if  not  put  on  too  tightly,  is  more  comfortable  and  more 
effective  than  a  non-elastic  bandage. 


CHAPTER  X. 

DISLOCATION  OF  THE  LOWER  JAW. 

The  mandibular  joint  is  made  up  of  the  condyle  of  the  mandible 
below,  and  the  glenoid  fossa  and  articular  eminence  on  the  under  sur- 
face of  the  temporal  bone  above.  Posteriorly,  the  glenoid  fossa  is 
bounded  by  the  delicate  tympanic  plate,  which  separates  it  from  the 
external  auditory  canal.  The  roof  between  the  glenoid  fossa  and  the 
middle  cerebral  fossa  is  very  thin.  Between  the  condyle  and  the  tem- 
poral bone  there  is  an  intraarticular  fibrocartilage  that  divides  the  joint 
into  two  compartments.  It  is  surrounded  by  a  capsular  ligament, 
while  three  other  ligaments,  which  are  described  later,  add  to  its 
strength   (Figs.  80  and  81). 

KINDS  OF  DISLOCATIONS. 

There  are  four  varieties  of  dislocation  at  this  joint  that  have  been 
described:  forward,  which  is  the  ordinary  form,  and  usually  uncom- 
plicated by  any  fracture ;  and  an  upward,  a  backward,  and  an  outward 
dislocation.  Instances  of  the  occurrence  of  any  of  the  latter  three 
varieties  are  extremely  rare,  and  each  of  them  is,  of  necessity,  accom- 
panied by  a  fracture.  Albert  states  that  the  condyle  may  be  dislocated 
backward  below  the  external  auditory  canal,  which  could  occur  with- 
out a  fracture.  For  convenience,  the  latter  three  will  be  considered 
first. 

Upward  Dislocation. — A  severe  upward  blow  on  the  chin  while 
the  mouth  is  open,  or  an  upward  blow  under  the  angle,  if  the  upper 
or  lower  posterior  teeth  are  missing,  might  drive  one  or  both  condyles 
through  the  roof  of  the  glenoid  fossae  into  the  skull.  In  such  an  in- 
jury the  movement  of  the  jaw  would  be  limited,  and  the  ramus  would 
be  apparently  shortened.     Le  Fevre  reports  such  a  case. 

Treatment  would  consist  in  trephining  above  the  glenoid  fossa,  ex- 
tracting the  condyle,  and  possibly  draining  the  middle  cerebral  fossa. 
The  mandible  could  be  retained  in  position  by  appropriate  dental  fixa- 
tion. In  one  case  of  partial  upward  dislocation  we  simply  wired  the 
jaws  together  for  five  weeks. 

Backward  Dislocation. — A  backward  blow  on  the  chin  while  the 
mouth  is  closed  might  drive  the  condyle  against  the  tympanic  plate 
with  such  force  as  to  crush  it  into  the  external  auditory  canals.  The 
chin  would  recede,  and  there  would  probably  be  bleeding  from  the  ca- 
nals ;  and  an  examination  with  an  aural  speculum  would  show  obstruc- 

146 


DISLOCATION  OF  THE  LOWER  JAW. 


147 


tion  of  the  canal.  The  condyle  would  be  felt,  or,  with  an  x-ray  exami- 
nation, would  be  seen  to  be  in  an  abnormal  position.  If  the  backward 
dislocation  is  unilateral,  the  chin  will  deviate  to  that  side. 

Treatment  will  consist  in  drawing  the  jaw  forward  and  retaining 
it  by  dental  fixation.  (See  methods  under  Fracture  of  the  Mandible, 
Chapter  VIII.)  An  attempt  should  be  made  to  restore  the  auditory 
canal. 


Fig.  80.  Ligaments  of  the  temporomandibular  joint  viewed  from  tlae  external  sur- 
face.    A,  capsular  ligament ;  B,  stylomandibular  ligament. 

Outward  Dislocation. — Robert  has  reported  a  case  of  outward 
dislocation.  The  body  was  fractured  in  front  of  the  angle,  and  the 
condyle  was  to  the  outer  side  of  and  above  the  zygoma.  To  reduce 
the  dislocation,  the  ramus  was  pushed  outward  until  the  condyle  was 
freed  from  the  zygoma,  and  the  condyle  was  pushed  down  and  into 
place.  The  jaw  should  then  be  treated  as  in  a  fracture  in  front  of  the 
angle. 

Forward  Dislocation. — Even  this  form  of  dislocation  is  com- 
paratively rare,  and  is  more  frequent  in  females  than  in  males.  It  has 
occurred  as  the  result  of  drawing  on  the  jaw  in  an  attempt  to  deliver 


148 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  head  in  difficult  labor,  but  it  is  much  more  rare  in  children  and  in 
elderly  people  than  in  the  prime  of  life.  When  the  jaws  are  closed, 
the  condyle  rests  in  the  glenoid  fossa ;  but  as  the  mouth  opens,  the  axis 
of  motion  being  in  the  neighborhood  of  the  inferior  dental  foramen, 
the  condyle  travels  forward  on  the  articular  eminence.  If  from  any 
cause  the  condyle  is  forced  but  a  little  past  the  crest  of  the  eminence, 
usually  without  a  rupture  in  the  capsular  ligament,  it  may  become 
locked  in  that  position.  This  constitutes  an  anterior  or  the  common 
dislocation  of  the  jaw.  The  determining  cause  is  usually  an  over- 
activity of  the  external  pterygoid  muscle,  assisted  possibly  by  the  pos- 
terior fibers  of  the  masseter,  when  the  mouth  is  fully  open.  More 
rarely  it  is  due  to  a  backward  blow  on  the  chin  when  the  mouth  is 


Fig.  81.  Temporomandibular  joint.  A,  capsular  ligament ;  B,  external  auditory 
canal;  C,  ma.stoid  processes:  D,  upper  joint  compartment;  B,  intraarticular  cartilage; 
F,  articular  eminence ;   G,  zygoma ;  H,  mandible. 

open,  which,  by  forcing  the  body  and  lower  part  of  the  ramus  back- 
ward, at  the  same  time  throws  the  condyle  forward.  The  jaw  has  been 
dislocated  in  the  act  of  drawing  a  tooth,  but  in  this  case  the  dislocation 
is  more  probably  due  to  muscular  action,  or  from  opening  the  mouth 
too  widely,  than  from  the  force  used  in  the  extraction.  A  unilateral 
dislocation  has  been  produced  by  a  blow  on  the  posterior  border  of 
the  ramus. 

The  amount  of  displacement  varies  greatly  in  different  cases.  In 
a  few  the  coronoid  process  has  become  engaged  under  the  malar  bone, 
and  this  has  been  regarded  by  some  as  the  factor  that  prevents  reduc- 
tion in  all  instances,  which  is  true  probably  in  but  a  very  small  per- 
centage of  cases.  The  condition  in  most  anterior  dislocations  of  the 
jaw  does  not  differ  materially  from  that  in  a  dislocation  of  the  hip 
or  shoulder.  In  each  of  these  joints  the  head  of  the  bone  is  held  in 
a  socket  by  the  tension  of  the  muscles  and  ligaments.     If  the  head 


DISLOCATION  OF  THE  LOWER  JAW.  149 

once  crosses  the  raised  border  that  surrounds  the  socket,  the  same  mus- 
cular and  ligamentous  pull  holds  the  head  in  its  new  position,  and  it  is 
only  by  some  manipulation  that  either  relaxes  or  overcomes  this  mus- 
cular ligamentous  pull  that  the  head  can  be  returned  to  its  socket.  This 
view  with  reference  to  anterior  dislocation  of  the  jaw  has  been  ex- 
pounded at  various  times,  but  it  is  most  clearly  presented  by  Dr.  Lewis 
A.  Stimson  in  his  classic  chapter  on  dislocations  of  the  lower  jaw;  and 
we  are  in  such  full  agreement  with  the  views  which  he  holds  that  we 
cannot  help  following  his  text  rather  closely.  Perthes  and  Albert  ex- 
press no  opinions  radically  different  from  those  of  Stimson,  and  in  the 
main  corroborate  his  views. 

Besides  the  capsular,  the  joint  is  protected  by  three  other  strong 
ligaments :  the  stylomandibular,  extending  from  the  styloid  process  to 
the  posterior  border  of  the  ramus ;  the  external  lateral,  closely  incor- 
porated with  the  capsular  ligament ;  and  the  internal  lateral,  which  is 
attached  above  to  the  spine  of  the  sphenoid  and  below  to  the  spine 
of  the  mandible.  Of  these  the  external  is  the  shortest  and  strongest, 
and  is  most  closely  concerned  in  maintaining  the  head  in  its  false  posi- 
tion when  it  becomes  dislocated  anteriorly,  the  other  ligaments  con- 
tributing. When  the  condyle  occupies  the  glenoid  fossa,  the  direction 
of  the  external  ligament  is  downward  and  backward.  As  the  condyle 
travels  forward,  the  point  of  attachment  of  the  ligament  on  the  neck 
assumes  a  position  directly  inferior  to  its  upper  attachment.  This 
would  allow  the  ligament  to  become  slack  if  the  plane  of  the  posterior 
surface  of  the  eminence  were  not  downward  and  forward.  When  the 
head  reaches  the  crest  of  the  eminence,  the  neck  of  the  jaw  and  the 
ligaments  are  in  the  same  plane,  and  the  latter  is  tense  (Fig.  80).  For 
the  head  to  travel  farther  forward  without  rupture  of  the  ligaments, 
the  axis  of  motion  must,  for  the  moment,  change  from  near  the  en- 
trance of  the  dental  canal  to  the  point  of  insertion  of  the  external 
lateral  ligament.  The  head  first  tilts  forward  on  this  new  axis, 
and  then  by  the  continuance  of  the  force  slides  onward,  carrying 
the  inferior  attachment  of  the  ligament  with  it  until  the  ligament  is 
again  taut.  Where  an  anterior  dislocation  has  occurred,  the  direc- 
tion of  the  combined  pull  of  the  muscles  of  mastication  is  such  as 
to  hold  the  lower  attachment  of  the  ligament  forward.  The  muscles 
of  mastication  can  no  longer  tilt  the  head  backward,  as  they  do  under 
normal  conditions,  for  now,  with  the  ligament  serving  as  a  fulcrum, 
the  posterior  surface  of  the  head  is  jammed  against  the  eminence  by 
the  temporals,  the  internal  pterygoid,  and  the  anterior  part  of  the  mas- 
seter,  thus  pulling  forward  and  upward  on  the  long  end  of  the  lever. 
It  is  probable  that  in  most  anterior  dislocations  the  ligaments  are 
not  ruptured.     Perthes  holds  this   view,   and  Albert  quotes   Schnitz- 


150  SURGERY  OF  THE  MOUTH  AND  JAWS. 

ler  as  being  unable  to  tear  the  ligaments  in  producing  a  disloca- 
tion on  the  cadaver.  There  are,  however,  undoubted  instances  where 
the  capsule  has  been  torn,  and  it  is  likely  that  this  occurs  in  all 
cases  of  primary  dislocation  where  the  head  travels  well  forward  of 
the  eminence.  In  these  instances  the  head  is  held  in  its  new  position 
by  the  muscles  and  the  stylomandibular  and  internal  ligaments.  The 
position  of  the  meniscus  in  an  anterior  dislocation  is  a  matter  of  some 
uncertainty.  It  is  probable  that  it  usually  remains  in  place,  the  con- 
dyle slipping  in  front  of  it,  but  in  some  recorded  instances  this  has  not 
been  the  case.  It  is  a  very  old  idea  held  by  Hippocrates,  and  many 
others  since  his  time,  that  reduction  is  prevented  by  the  coronoid  be- 
coming engaged  under  the  malar  bone.  While  there  is  on  record  one 
undoubted  instance  of  this  occurrence,  it  is  rare.  According  to  Per- 
thes, however,  in  50  per  cent  of  the  cases  the  coronoid  coming  in 
contact  with  the  zygoma  helps  to  prevent  the  closure  of  the  jaws. 

Symptoms  of  Anterior  Dislocation. — The  mouth  is  at  first  held 
open,  and  chewing  is  impossible.  The  chin  is  slightly  forward,  swal- 
lowing and  talking  are  difficult,  and  the  muscles  are  usually  tense. 
Most  important  of  all,  the  absolute  sign,  the  condyle  may  be  felt,  or 
seen  by  means  of  the  x-ray,  to  be  in  advance  of  its  natural  position. 
In  a  unilateral  dislocation,  the  chin  deviates  to  the  opposite  side. 

TREATMENT. 

The  treatment  consists  in  reducing  the  dislocation  and  holding  the 
head  in  the  socket  by  artificial  means  until  the  stretched  or  torn  liga- 
ments have  time  to  unite  or  recover  their  normal  tone.  Reduction  may 
be  accomplished  in  one  of  two  ways:  (1)  by  traction  that  forces  the 
ligaments  and  muscles  to  yield  sufficiently  to  allow  the  head  to  pass 
the  obstruction  and  slip  into  the  socket,  or  (2)  by  manipulations  that 
bring  the  head,  in  reverse  order,  into  the  various  positions  which  it 
assumed  while  leaving  the  fossa.  The  latter  course  is  the  preferable 
way,  requiring  less  force  and  inflicting  less  pain ;  while  the  former,  by 
stretching  the  lateral  ligaments,  might  inflict  more  damage  to  the  joint 
than  was  sustained  at  the  original  injury. 

Reduction  by  Traction.- — This  is  accomplished  by  grasping  the 
body  of  the  jaw  on  each  side,  with  the  thumbs  on  the  occlusal  surfaces 
of  the  molars,  and,  while  making  downward  traction  on  the  rami,  mak- 
ing an.  attempt  to  raise  the  chin  and  push  the  condyles  backward  into 
the  sockets.  The  attempt  may  be  made  on  one  side  at  a  time.  In 
doing  this,  the  thumbs  must  be  protected  by  a  thick  wrapping  of  gauze, 
or  otherwise  they  may  sustain  injury  when  the  jaws  snap  together.  If 
the  reduction  cannot  be  done  with  the  unaided  hands,  as  suggested 
by  Gilmer,  a  stout  stick  may  be  placed  in  the  mouth,  one  end  of  which 


DISLOCATION  OF  THE  LOWER  JAW.  151 

rests  on  the  inferior  molars  of  one  side,  while  the  upper  molars  on  the 
other  side  are  used  as  a  fulcrum,  and  in  this  way  the  ramus  may  be 
pried  downward.  The  teeth  should  be  protected  by  rubber  tubing  or 
gauze  while  this  is  being  done.  The  reduction  is  facilitated  by  an  an- 
esthetic. 

Reduction  by  Manipulation. — It  is  not  an  uncommon  occurrence 
for  an  anterior  dislocation  to  become  reduced  spontaneously,  and  as 
Stimson  points  out,  the  most  gentle  methods  that  have  been  found  suc- 
cessful are  those  which  carry  the  condyle  back  through  the  positions  it 
assumed  while  leaving  the  socket.  In  many  instances,  however,  these 
manipulations  were  carried  on  without  a  true  understanding  of  the 
mechanism  that  hindered  reduction.  Hippocrates  supposed  that  reduc- 
tion was  prevented  by  the  coronoid  being  engaged  on  the  malar  bone; 
and  in  order  to  free  it,  he  depressed  the  chin  and  pushed  the  jaw  back- 
ward, at  the  same  time  encouraging  the  patient  to  voluntarily  relax  the 
muscles.  Galen  and  others  have  followed  this  method.  For  the  most 
part,  however,  it  was  lost  sight  of,  and  the  practice  of  using  force  to 
overcome  the  muscular  and  ligamentous  resistance,  as  described  above, 
has  for  a  long  time  been  the  one  now  widely  adopted.  Maisonneuve, 
in  1862,  after  a  careful  study  concluded  that  muscular  spasm  and  the 
resistance  of  the  ligaments  prevented  the  reduction,  and  that  these  could 
best  be  overcome  by  direct  backward  propulsion  after  opening  the 
mouth  more  widely.  The  spasm  of  the  muscles  should  be  overcome, 
either  with  the  assistance  of  the  patient  or  by  aid  of  an  anesthetic ;  and 
the  ligaments  are  relaxed  by  depressing  the  chin  and  pushing  backward 
on  the  rami.  The  theory  of  this  is :  that  as  the  chin  is  depressed  the 
lower  end  of  the  rami  travels  upward  and  backward,  which  relaxes  the 
ligaments  and  disengages  the  condyle  from  the  eminence.  As  the  back- 
ward pressure  on  the  rami  is  continued,  the  head  glides  over  the  crest 
of  the  eminence,  and  the  reduction  is  complete.  In  some  cases  all 
methods  short  of  cutting  down  upon  the  joint  will  fail.  In  one  case 
reported  by  Stimson,  the  meniscus  had  become  detached  and  was 
folded  up  in  the  glenoid  fossa,  preventing  the  head  from  entering. 
(For  the  technic  of  exposing  this  joint,  see  Chapter  XXII.) 

Retention. — When  the  dislocation  is  reduced,  means  must  be 
taken  to  prevent  its  recurrence.  The  head  cannot  become  dislocated 
until  it  rises  up  on  the  eminence,  which  does  not  begin  until  the  mouth 
is  opened  at  least  1  centimeter.  This  can  be  done,  as  suggested  by 
Stimson,  by  the  use  of  a  head-to-chin  bandage  for  three  weeks.  A 
very  much  neater  way  is  to  band  an  upper  and  lower  tooth,  a  canine 
or  first  bicuspid,  and  unite  them  with  a  strand  of  braided  silk  that 
will  allow  the  jaws  to  separate  1  centimeter.  For  an  acute  dislo- 
cation this  must  be  worn  for  three  weeks.     The  silk  or  silkworm  gut 


152  SURGERY  OF  THE  MOUTH  AND  JAWS. 

strand  may  have  to  be  removed  every  few  days,  but  if  necessary,  the 
patient  can  be  taught  to  do  this  himself. 

UNREDUCED  DISLOCATIONS. 

According-  to  Stimson,  the  prognosis  of  an  unreduced  anterior  dislo- 
cation is  not  bad.  The  condyle  and  ligaments  adopt  themselves  to  the 
new  position.  Reduction  should  even  be  attempted  some  time  after 
the  dislocation  has  occurred.  If  function  is  poor,  the  joint  should  be 
opened,  the  fossa  cleared,  and  the  condyles  replaced.  If  this  cannot 
be  done,  both  condyles  may  be  excised.  Mazzoni  excised  both  condyles 
in  one  case  eight  months  after  the  injury  with  good  functional  results. 
(For  technique,  see  Chap.  XXII.) 

CHRONIC  DISLOCATIONS. 

If  proper  means  are  not  taken  to  prevent  its  recurrence,  a  disloca- 
tion may  become  chronic,  the  condyles  slipping  forward  at  any  time 
when  the  mouth  is  widely  opened.  For  such  a  condition  Annandale 
opened  the  joint  and  stitched  the  meniscus  to  the  periosteum  in  two 
cases.  We  think  a  simpler  method  of  treating  such  a  condition  is  to 
limit  the  motion  of  the  jaw,  as  described  above.  We  once  had  a 
patient  wear  this  appliance  for  three  months  with  good  results. 

SUBLUXATION. 

It  is  not  an  uncommon  condition  for  the  condyle  to  catch  every  time 
the  mouth  is  widely  opened  and  to  recede  with  a  cracking  sound. 
In  older  persons  it  may  be  due  to  an  anthritis,  but  in  young  persons, 
with  lax  ligaments,  it  is  in  most  cases  either  a  subluxation  or  a  catch- 
ing of  the  meniscus.  Besides  general  tonic  treatment,  the  movement 
of  the  jaw  may  be  limited  until  the  ligaments  regain  a  healthful 
tone. 


CHAPTER  XL 

CONGENITAL  FACIAL  CLEFTS. 

The  general  relation  of  open  facial  clefts  to  the  embryonal  fissures 
has  long  been  established ;  but  there  are  certain  points  that  are  still  the 
subject  of  discussion,  and  the  cause  or  causes  of  their  partial  non- 
closure are  still  to  be  determined. 

MORPHOLOGY. 

After  the  fifteenth  day  from  conception,  the  cavity,  from  which  will 
be  formed  the  future  mouth  and  nose,  is  bounded  above  by  a  tubercle 


Fii 


82. 


Pig.    83. 


Pig.  82.  Head  of  fetus  at  end  of  fiftli  week  (after  His).  C,  frontonasal  process; 
B,  maxillary  process  ;  A,  mandibular  processes. 

Pig.  S3.  Head  of  fetus  in  the  seventh  weelv  (after  His).  A,  the  now  united  man- 
dibular processes ;  B,  the  maxillary  process ;  C,  frontonasal  process ;  D,  lateral  nasal 
process ;  E,  globular  processes  attached  to  the  nasal  part  of  the  frontonasal  process. 
The  central  nasal  processes  are  separated  from  the  lateral  on  each  side  by  the  lateral 
nasal  grooves,  which  represent  the  anterior  cares. 


projecting    from   the    anterior   part   of   the   head,   called   the   fronto- 
nasal process,  and  on  each  side  by  maxillary  processes  (Fig.  82).    The 

153 


154 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


mandibular  processes  join  in  the  midline  about  the  fifth  fetal  week,  and 
they  together  form  the  lower  jaw,  which  represents  the  first  pair  of 
visceral  arches.  The  maxillary  processes  do  not  meet  in  the  midline, 
but  remain  wedged  between  the  frontal  and  the  mandibular  parts.  The 
cavity  is  now  bounded  below  by  the  mandible,  laterally  by  the  max- 
illary, and  above  by  the  frontal  processes.  About  this  time  there  ap- 
pear on  the  lower  end  of  the  developing  frontal  process  three  tubercles, 
which  are  in  turn  called  the  central  and  two  lateral  processes.  Each 
lateral  tubercle  is  separated  from  the  central  by  a  short  fissure  called 
the  lateral  nasal  groove,  or  olfactory  pit  (Fig.  83).  Farther  on  the 
lower  border  of  the  central  processes  are  developed  two  other  tubercles 


Fig.   84.      Schematic  diagram,  modified  from  Merkel,  showing  plan  of  facial  clefts. 

which  are  called  the  globular  processes,  and  these  are  separated  from 
each  other  by  a  single  central  groove.  From  the  frontonasal  process 
with  the  nasal  processes  will  be  formed  the  forehead,  external  nose, 
and  central  part  of  the  lip. 

The  maxillary  processes  are  separated  from  the  frontal,  which  now 
include  the  lateral  nasal  and  globular  processes,  by  the  orbital  fissure 
which  extends  to  the  mouth,  in  the  upper  part  of  which  the  eye 
is  developed.  Somewhere  below  its  middle  the  orbital  fissure  is  joined 
by  the  lateral  nasal  groove,  and  together  they  have  been  described  by 
Merkel  as  a  Y-shaped  cleft. 

The  lower  single  limb  of  the  Y  opens  into  the  mouth ;  while  the  ex- 
ternal upper  limb  extends  to  the  eye,  and  the  upper  median  limb  is  the 


CONGENITAL  FACIAL  CLEFTS. 


155 


lateral  nasal  gfoove  which  separates  the  lateral  nasal  from  the  central 
nasal  process.  The  frontonasal  and  maxillary  processes  are  separated 
from  the  lower  jaw  by  a  transverse  fissure,  the  median  part  of  which 
will  be  the  future  external  mouth  slit. 

By  the  non-closure  of  any  part  of  the  Y-shaped  fissures,  the  trans- 
verse mouth  fissures,  or  the  cleft  that  existed  in  the  midline  between 
the  mandibular  processes,  or  the  median  groove  between  the  globular 
processes  are  produced  any  and  all  of  the  typical  face  clefts  which  are 
here  schematically  illustrated  by  a  slightly  modified  diagram  from  Mer- 
kel  (Fig.  84). 


Fig.    85. 


Fig.    86. 


Fig.  85.  Diagram  of  oblique  facial  cleft.  The  cleft  shown  in  this  diagram  corre- 
sponds to  the  cleft  5-4-6   in  Merkel's  diagram    (Fig.   84). 

Fig.  86.  Oblique  facial  cleft,  complete  into  palpebral  fissure  on  subject's  left  side. 
— From  specimen  in  the  London  Hospital  Museum,  photographed  for  this  book,  by  cour- 
tesy of  the  curator. 


Types  of  Clefts. — If  the  maxillary  fails  to  unite  with  the  frontal 
process  throughout  the  entire  extent  of  the  fissure,  there  will  be  a 
cleft  extending  from  the  mouth  through  the  lateral  part  of  the  upper  lip 
to  the  eye  and  possibly  beyond :  obliquely  facial  cleft  (Figs.  85  and  86). 
If  the  maxillary  fails  to  unite  to  the  globular  process,  there  will  be  a 
cleft  extending  through  the  lateral  part  of  the  lip  toward  or  into  the 
nostril:  ordinary  harelip  (Figs.  87  and  88).  If  the  two  globular  proc- 
esses fail  to  unite  with  each  other,  there  will  be  a  median  harelip  which 
is  usually  only  a  notch  (Figs.  89,  90,  and  91).   From  failure  of  closure 


156 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


of  the  lateral  parts  of  the  transverse  mouth  cleft,  an  abnormally  large 
moutli  slit  results:  macrostomia  (Figs.  92,  93,  and  94).  Finally,  if  the 
two  mandibular  processes  fail  to  unite  in  the  midline,  a  median  cleft  of 
the  lower  lip  and  possibly  the  jaw  and  tongue  is  the  result  (Fig.  95). 
The  failure  of  closure  of  any  or  all  of  the  clefts  may  be  so  slight  as  to 
leave  only  a  lip  notch,  or  so  complete  as  to  involve  the  whole  of  the 
fissure,  extending  even  into  the  base  of  the  skull  and  brain,  or  to  the 
ears  or  down  to  the  sternum. 

In  presenting  the  above,  the  writer  has  followed  the  rather  generally 
accepted  theory  that  the  lateral  nasal  process  does  not  extend  down  to 


Fig.   87.      Diagram    of    ordinary    harelip. 
Fig.   88.      Almost   complete    single    harelip. 
Fig.   89.      Diagram  of  median   harelip. 


Pig.    89. 


the  mouth,  that  it  takes  no  part  in  the  formation  of  the  lip,  and  that 
all  lip  clefts  lie  between  the  globular  and  the  median  nasal,  and  the 
maxillary  processes,  but  this  is  one  of  the  points  that  is  disputed  by 
Albrecht  and  his  followers.  They  maintain  that  the  lateral  nasal 
process  extends  normally  to  the  transverse  mouth  slit,  that  it  forms  part 
of  the  upper  lip  and  the  palate,  and  that  a  lateral  lip  cleft  runs  between 
it  and  the  globular  process.  This  cannot  be  absolutely  disproved,  but 
it  is  denied  by  the  majority  of  embryologists ;  and  Merkel  asserts  that 
the  lateral  nasal  process  under  abnormal  conditions  remains  entirely  shut 
out  from  the  formation  of  the  lip  and  intermaxillary  process.     What 


CONGENITAL  FACIAL  CLEFTS. 


157 


happens  under  normal  conditions  is  not  so  plain,  and  the  study  of  cases 
of  oblique  facial  cleft  does  not  solve  the  question.  In  these  cases  the 
cleft  may  extend  through  the  lip  directly  to  the  eye,  in  which  event  it 
could  be  skirting  a  lateral  nasal  process  throughout  its  entire  extent ; 


Fig.  90.  Median  fissure  of  upper  lip  due  to  absence  of  tlie  intermaxillary  procesess. 
— From  specimen  in  the  Royal  College  of  Surgeons  Museum,  London,  photographed  for 
this  boob,  by  courtesy  of  the  curator. 


Fig.  91.  Skull  from  specimen  shown  in  Fig.  90. — From  a  specimen  in  the  Royal 
College  of  Surgeons  Museum,  London,  photographed  for  this  book,  by  courtesy  of  the 
curator. 


or  it  may  extend  through  the  lip  into  the  nostril,  and  then  around  the 
ala  to  the  eye,  which  would  be  utter  disregard  of  any  part  of  the  lateral 
nasal  process  below  the  ala.  These  two  varieties  of  facial  cleft  are  de- 
picted in  Merkel's  diagram    (Fig.   84).     The  relation   of  the   lateral 


158 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


process  to  the  lip  and  palate  will  be  again  considered  with  clefts  of 
the  latter. 

The  palate  is  a  part  of  the  face.  Its  anterior  portion  as  far  back 
as  the  incisive  fossa  is  formed  by  the  frontonasal  process.  The  max- 
illary processes  through  their  palate  ridges  extend  to  the  midline  be- 


Fig.  94. 


Fig.  92. 
Fig.  93. 
Fig.    94. 


Diagram    of    macrostomia. 

Macrostomia.      Less   degree   than    in    the    preceding. 

Macrostomia.  The  oblong  opening  behind  the  mouth  slit  is  from  the  re- 
moval of  a  piece  of  tissue  for  examination. — From  specimen  in  the  Royal  College  Mu- 
seum, London,  photographed  for  this  book,  by  courtesy  of  the  curator. 

hind  the  frontonasal  process  and  form  the  remainder  (Fig.  96).  The 
palate,  therefore,  is  made  up  of  three  parts  which  were  originally  sep- 
arated from  each  other  by  another  Y-shaped  fissure.  The  vertical  stem 
of  this  Y  was  posterior  and  lay  between  the  two  maxillary  parts,  while 
the  two  short  oblique  arms  were  anterior  and  separated  the  palate  sur- 
face of  the  frontonasal  process  from  the  palate  surface  of  the  maxillary 


CONGENITAL  FACIAL  CLEFTS.  159 

processes   (Fig;  97).     These  and  face  fissures  are  but  different  views 
of  the  same  through-and-through  clefts. 

If  the  whole  of  the  Y-shaped  palate  fissure  fails  to  close,  there  re- 
sults a  complete  cleft  which  is  double  anteriorly,  while  partial  failures 
cause  lesser  clefts  in  various  parts.  These  clefts  will  always  be  median 
behind  the  anterior  palatine  fossa  and  will  be  lateral  in  front  of  it,  un- 


<J^J^ 


Fig.   95.      Diagram    of    cleft    of    lower    lip. 

less  there  has  been  a  complete  failure  of  union  between  the  globular 
processes,  in  which  case  there  might  be  a  median  anterior  palate  cleft 
corresponding  to  median  cleft  of  the  upper  lip.  Such  clefts  are  re- 
ferred to  by  Lannelongue  and  Witzel.  This  anterior  median  palate 
cleft  is  the  rarest  of  all  typical  clefts. 


Fig.  96.  Diagrammatic  reconstruction  of  the  palate  in  the  sixth  fetal  week.  C,  C, 
inti;rmaxillary  part  of  the  palate  and  central  part  of  the  upper  lip  derived  from  the 
frontonasal  process;  B,  lateral  part  of  the  lip;  A,  alveolar  process;  P,  palate  process: 
all  derived  from  the  maxillary  process. 

We  have  had  one  median  cleft,  which  was  possibly  due  to  a  lack  of 
development  of  the  globular  process.  The  cleft  in  the  alveolus  was 
median,  but  the  columella  had  a  slightly  lateral  attachment.  There 
have  been  a  few  instances,  where  the  two  sides  of  the  nose  have  been 
separated  by  a  median  longitudinal  furrow,  extending  from  the  lip  to 
the  frontal  bone.     The  exact  embryological  significance  has  not  been 


160 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


demonstrated.  A  mild  form  of  this  condition  is  sometimes  seen  in 
pointer  dogs. 

The  part  of  the  palate  that  is  derived  from  the  frontal  process  is 
represented  by  the  intermaxillary  bones  and  their  mucous  covering. 
These  are  continuous  with  the  nasal  septum  which  is  derived  from  the 
same  source.  Later  the  septum  joins  the  palate  ridges  when  they  meet 
in  the  midline,  and  thus  the  nose  and  mouth  are  separated  into  three 
cavities. 

If  the  palate  ridges  fail  to  unite  with  each  other,  the  nasal  septum 
will  also  fail  to  unite  with  one  or  both  of  them,  and  through  the  re- 
sulting median  cleft,  the  mouth  cavity  will  communicate  with  one  or 
both  nasal  fossae  accordingly.     While  embryologically  the  cleft  is  median 


Pig.  97.  Diagram  -showing  Y-shaped  complete  cleft  of  the  palate  :  a,  central  in- 
cisor ;  b,  canine  ;  c,  first  molar ;  d,  second  molar. 

behind  the  incisive  fossa,  it  is  often  thrown  to  one  side  by  the  greater 
development  of  one  palate  ridge. 

Closure  of  the  palate  fissures  occurs  first  anteriorly  and  extends 
backward,  the  two  halves  of  the  velum  being  the  last  to  unite.  It  is 
complete  in  the  ninth  week,  and  any  agency  that  interferes  with  the 
closure  must  have  acted  before  this  time. 

RELATION  OF  THE  ALVEOLAR  CLEFT  TO  THE  TEETH. 

The  varying  position  of  the  cleft  in  the  alveolus  with  regard  to 
the  incisor  teeth  has  been  a  subject  of  interest  and  the  cause  of  much 
discussion.  In  the  majority  of  instances,  the  lateral  incisor  is  missing, 
and  the  cleft  lies  between  the  central  incisor  and  the  canine  tooth. 
There  may  be  two  incisors  in  front  and  a  canine  behind,  or  the  cleft 
may  extend  between  two  incisors,  or  there  may  even  be  two  incisors 


CONGEMITAJL  FACIAL  CLEFTS. 


161 


in  fcomt  amd  a  liMrd  imosor  ludmoad  the  deft.   ^msMj, 
at  least  two  imstainces  isu  tlhie  IhnnnnniaTni  and  one  im  a.  dog'  in 
ram  br/  "  f  :"Te  camime. 

Fergus  Ill's  Tlie<Mry> — Tlae  lack  off  an  incisor  at  i 
was  expl 


aie  ir^oirted 
wlsidi  ttiip  cle& 


the  site  oi  the 
ssHpposHtiGn  that 


i         ^ 


cjfeft  iin  wMafii  atr  BiinlrBB  a  lioiiafi&i  Bannsig  irinininiii 
tke  latft'Effilj  nmaurgSm  cuff  t£B»  aLthreGBllaur  idtetfi 


JFbe.    *>£!..       (Case    nif    .tiiinmfjBfaii 
eil^t,  iffl  ■wftatfti  mraEttBa  Ibimfls  jBinuHji'iuSeS  fenna 


"^^K. 

"«i 

wk  ^^1 

L*' 

|3p^^ 

k 

'i 

l^m- 

Fig.  9®.     iraife  (ieffoBinnifiiiy  fe  ssnniffwfnatt  irfflme  aimfl  ftiais,   inm  ttBae 
(SensftoHiKffl :  ai  nniiffllSm)®  a'Bsfflr  lEffltt  teeiiiaig  inn  (tsBmfflwnntiilij'  wfittBa  IkuMaswim 
tfifftaDaur  fioisttainxfe'  uflne  (ffleffcniniffluiitjr  'wsbs  ebsas-  Hbb  BIDS'  ^at  ttlmtr  ttflup  nm 


iDaagsr.     Im  aflofe  pair- 


mnMIlniDe  aaxS  tiftie  sarenmaisSlIIla  ajsKi  pirsBllaBBiinniiffli   ((ttSas'  toTsrsir  ssiafl  off  ttBog' 
'VK^re  aiScQiwe  >Lte  iraaxSIIMe  attttaidteri  ten  tLBoe-  sDasaill  septnmm  -nriittMm  it&e 


ifmmnnltimmiaisaill    JsniBatesSJ) 


it  had  heen  lost  mm  the  deft ;  and  in  this  he  is  simpported  hj  Wamraekros, 
and  oar  observaticms  denoonstirate  the  possibility^  of  socfa  an  occurrence. 
We  faaTe  seen  a  nnnDber  of  cases  where  the  tooth  bads  protrnded  into 
the  deft  or  were  sraspemded  by  a  slosder  pedide  (Figs.  StiSA  and  @8B}. 
'Wamekrosf  Theory. — ^Whem  am  incisoir  is  missing"  in  a  case  of 
defit  of  1^  or  palate  ^^f  ^iparentlj  does  not  invidine  the  ahnedar 


162  SURGERY  OF  THE  MOUTH  AND  JAWS. 

process,  according  to  Warnekros,  it  lies  hidden  in  an  occult  bony  cleft 
that  does  not  involve  the  gum  tissue. 

KoUiker's  Theory.— From  Goethe  to  Kolliker  all  surgeons 
adopted  the  simple  view  that  the  cleft  ran  between  the  part  of  the  max- 
illa that  is  derived  from  the  original  maxillary  process,  and  the  inter- 
maxillary bone  which  is  part  of  the  original  frontal  process. 

Albrecht's  Theory. — Later  Albrecht  advanced  the  theory  that 
the  intermaxillary  bone  in  development  consists  of  not  one  part  on 
each  side,  but  two  distinct  pieces,  each  carrying  an  incisor,  and  that 
the  cleft  runs  between  these  two  pieces.  Albrecht's  theory  is  a  pure 
hypothesis,  and  no  direct  evidence  of  each  half  of  the  intermaxillary 
bone  developing  from  two  centers  has  been  discovered.  However,  as 
Sir  William  Turner,  after  discussing  the  question,  has  pointed  out: 
"It  should  not  be  forgotten  that  it  is  quite  recently  that  the  embryolog- 
ical  evidence  of  the  origin  of  the  intermaxillary  part  of  the  human  up- 
per jaw  from  a  center  distinct  from  that  of  the  maxilla  has  been  com- 
pleted, and  yet  for  nearly  a  century,  on  such  minor  evidence  as  was 
advanced  by  Goethe — namely,  the  suture  on  the  hard  palate  extending 
through  the  nasal  surface — anatomists  have  believed  and  taught  that 
the  upper  human  jaw  represented  both  the  maxillary  and  intermaxillary 
bones  in  any  mammal.  Where  a  question  of  human  embryology  hinges 
upon  an  examination  of  parts  in  a  very  early  stage  of  development,  we 
often  have  to  wait  for  many  years  before  an  appropriate  specimen  falls 
into  the  hands  of  a  competent  observer." 

Albrecht  accounts  for  the  occasional  condition  of  two  incisors  in 
front  of  the  cleft  as  an  atavistic  development  of  a  third  incisor;  it  is 
the  central  incisor  that  we  are  supposed  to  have  lost,  but  a  cleft  behind 
the  canine  finds  no  place  in  his  hypothesis.  The  latter  condition  must 
be  explained  on  one  of  two  suppositions :  either  a  band  has  cut  into 
the  maxilla  behind  the  canine,  or  the  canine  has  developed  from  that 
part  of  the  dental  ledge  that  attached  itself  to  the  premaxilla.  The 
majority  of  embryologists  support  the  view  championed  by  Kolliker. 

Although  this  varying  relation  of  the  incisor  teeth  to  the  cleft  has, 
in  different  instances,  been  advanced  as  an  argument  to  support  one 
or  the  other  theory,  it  is  probable  that  it  is  not  pertinent  to  the  dis- 
puted question  as  to  whether  each  half  of  the  intermaxillary  consisted 
originally  of  one  or  two  pieces.  It  seems  likely  that  the  original  posi- 
tion of  the  tooth  sacs  of  the  incisors  is  not  fixed  in  regard  to  the  max- 
illary and  intermaxillary  processes,  and  that  the  papilla,  from  which 
the  lateral  incisor  will  develop,  may  spring  from  either  border  of  the 
cleft.  The  dental  ledges  from  which  the  teeth  develop  are  formed  by 
an  infolding  of  the  mucous  membrane  of  the  mouth,  which  occurs  in 
the  seventh  fetal  week.     The  relationship  which  it  acquires  to  the 


CONGENITAL  FACIAL  CLEFTS. 


163 


mesodermic  tissue  of  the  jaws  is  a  secondary  one.  In  the  ninth  week 
distinct  evidence  of  the  future  separation  into  individual  teeth  can  be 
made  out.  This  latter  occurs  very  shortly  after  the  ossific  centers  of 
the  maxillae  first  appear,  and  a  reasonable  supposition  is  that,  as  the  re- 
lation of  the  teeth  to  the  bones  is  an  acquired  one,  the  relation  of  indi- 
vidual teeth  to  the  cleft  is  somewhat  accidental. 

CLINICAL  TYPES  OF  CONGENITAL  CLEFTS. 

The  deformity  that  is  most  commonly  brought  to  the  surgeon  is 
complete  single  cleft  of  the  lip  and  palate.     If  the  cleft  in  the  lip  is 


/' 


^        J 


Fig.  100.  Double  cleft  of  the  lip,  incomplete  on  one  side.  In  this  case  the  alveolar 
process  was  cleft  only  on  one  side,  but  posteriorly  there  was  a  double  cleft  of  the  hard 
palate.     This  is  a  not  infrequent  occurrence. 


Fig.   101.      Complete  double  cleft  of  the  lip.      This  is  here  accompanied  by  a  double 
cleft  of  the  palate.     The  intermaxillary  bone  carries  three  incisors. 


double,  it  may  be  incomplete  on  one  side  (Fig.  100).  If  it  is  a  complete 
double  cleft  of  the  lip,  there  will  also  almost  always  be  a  complete  dou- 
ble cleft  of  the  palate  (Figs,  101,  84,  and  86).  Cleft  palate  may  occur 
without  a  harelip,  or  more  rarely  a  harelip  occurs  without  any  bony 
cleft ;  but  it  often  accompanies  a  cleft  limited  to  one  side  of  the  alveolus. 


164 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Cleft  of  the  velum  alone  is  common  enough,  but  cleft  of  the  midpart 
of  the  palate  with  intact  velum   is  very  rare.     Oblique   facial   clefts. 


Pig.  102.  Skull  of  an  adult  who  had  a  complete  single  cleft  of  the  lip  and  palate. 
TTiis  deformity  had  never  been  corrected  as  shown  by  the  lack  of  approximation  of  the 
alveoli  at  the  anterior  part  of  the  cleft. — From  a  specimen  in  the  Royal  College  of  Sur- 
geons Museum,  London,  photographed  for  this  book,  by  courtesy  of  the  curator. 


Fig.  103.  Skull  of  an  adult  who  had  a  double  cleft  of  the  palate  behind  the  Incisive 
fossa.^ — From  a  specimen  in  the  Royal  College  of  Surgeons  Museum,  London,  photo- 
graphed for  this  book,  by  courtesy  of  the  curator. 

macrostomia,  and  central  clefts  of  the  upper  and  lower  lips  or  jaws  are 
among  the  rare  surgical  curiosities.    (See  Fig.  99.) 

THEORIES  OF  FAILURE  OF  CLEFT  CLOSURE. 

The  exact  reason  for  the  failure  of  closure  of  the  cleft  has  ever 
been  a  source  of  speculation. 

Heredity. — The  influence  of  heredity  is  very  striking^  but  it  has 
been  difficult  for  us  to  compute  its  bearing  with  any  exactitude  in 


CONGENITAL  FACIAL  CLEFTS.  165 

our  cases.  In  a  large  number  of  the  cases  the  lack  of  knowledge  on 
the  part  of  the  parents  precluded  the  possibility  of  getting  data  on  the 
subject.  In  spite  of  this,  the  proportion  of  cases  in  which  the  defect 
can  be  traced  through  the  immediate  or  collateral  branches  of  the  fam- 
ily is  very  large,  and  the  instances  are  often  very  striking.  It  is  not 
at  all  uncommon  to  find  patent  facial  clefts  in  two  children  of  the  same 
family,  and  in  one  instance,  we  saw  a  mother  and  child  both  with  cleft 
palate ;  and  she  informed  us  her  father  also  had  one,  but  she  knew  noth- 
ing of  his  progenitors.  Mr.  Owen  cites  a  family  in  which  a  number  of 
cases  had  occurred  during  several  generations,  both  in  the  immediate 
and  collateral  branches.  We  have  seen  a  number  of  families  who  were 
so  afiflicted,  and  in  such  cases  the  defect  is  often  manifested  in  various 
degrees.  A  mother  may  have  a  defective  or  absent  lateral  incisor,  and 
the  child  show  a  complete  cleft  palate ;  one  may  have  simply  a  peculiar 
enunciation,  where  others  in  the  family  may  have  harelip,  etc.  Hered- 
ity cannot  be  advanced  as  a  cause,  but  simply  as  a  transmission  of  a 
cause,  and  however  interesting  these  observations  may  be,  they  shed 
little  light  on  the  etiology. 

Mechanical  Cause. — In  speculating  upon  this  subject,  it  seems 
fair  to  assume  that  the  failure  of  closure  of  the  clefts  may  be  due  to 
more  than  one  determining  factor,  and  in  a  study  of  the  data  at  our 
disposal  two  possible  causes  stand  out  very  prominently:  (1)  that 
some  mechanical  obstruction  prevents  the  approximation  of  the  cleft 
borders;  (2)  that  some  influence  on  the  vital  forces  interferes  with 
union  after  the  borders  are  approximated.  Of  the  mechanical  influ- 
ences that  have  been  put  forward  as  the  possible  cause  of  the  defect, 
some  could  be  sufficiently  broad  in  their  action  to  account  for  all  in- 
stances of  patent  clefts ;  some  could  account  for  only  certain  limited 
clefts;  while  others  could  have  no  bearing  on  the  subject.  To  the  lat- 
ter class  belongs  the  explanation  of  Fein,  who  ascribes  clefts  of  the 
palate  to  hypertrophy  of  the  pharyngeal  tonsil.  This  view  is  opposed 
by  Tandler,  who  shows  that  between  closure  of  the  palate  clefts  and 
the  first  appearance  of  adenoid  tissue  two  fetal  months  elapse. 

The  following  may  be  included  among  the  possible  mechanical  in- 
fluences :  Before  the  development  of  the  palate  ridges  the  tongue  fills 
the  whole  mouth  and  nose  cavity,  and  its  failure  to  recede  from  the 
nasal  part  has  been  ascribed  by  Tandler,  Dursy.  and  others  as  a  cause. 
One  specimen  of  pig  embryo  has  been  observed  that  seems  to  support 
this  view.  In  conjunction  with  this  theory  Friedrich  states  that  the 
tongue  is  still  above  the  level  of  the  palate  in  the  second  half  of  the 
second  fetal  month  and  that  the  cleft  could  be  caused  mechanically  by 
the  pressure  of  some  underlying  structure  pressing  upward  on  the 
mandible.    In  one  case  a  left  hand  was  tucked  under  the  chin.     In  one 


166  SURGERY  OF  THE  MOUTH  AND  JAWS. 

case  preserved  in  the  Hunterian  Museum  of  London,  the  tongue  is  ad- 
herent by  a  bond  of  tissue  to  the  anterior  end  of  a  palate  cleft. 

Tumors. — Tumors  must  undoubtedly  be  the  cause  in  some  in- 
stances. Broca  found  a  tumor  of  the  base  of  the  skull  the  cause  of  a 
complicated  harelip,  and  Lannelongue  found  a  tumor  of  the  tongue 
accompanying  a  cleft  of  the  palate.  Reasoning  from  the  researches  of 
Bland-Sutton,  basicranial  teratomata  must  also  be  occasional  factors. 
When  of  sufficient  size  and  appearing  early,  tumors  might  cause  very 
extensive  clefts. 

Amniotic  bands  and  adhesions  are  so  often  associated  with  clefts 
and  deformities  as  to  leave  little  doubt  as  to  their  causative  influence. 
H.  Fronhofer  and  others  have  collected  evidence  which  shows  that 
amniotic  bands  and  adhesions  may  be  related  to  patent  clefts,  intra- 
uterine amputations,  skin  appendages,  and  other  deformities.  Broad 
adhesions  of  the  amnion  are  present  in  most  severe  facial  malforma- 
tions. It  is  possible  that  amniotic  bands  and  lack  of  liquor  amnii  are 
but  the  result  of  some  vital  defect. 

Supernumerary  Teeth. — Warnekros  has  made  a  valuable  study 
of  the  teeth  in  individuals  with  palate  cleft,  and  because  in  almost  every 
instance  he  was  able  to  demonstrate  supernumerary  teeth  either  show- 
ing in  the  mouth  or  buried  in  occult  bone  clefts,  he  concludes  that  su- 
pernumerary teeth,  by  requiring  more  room  than  is  normally  furnished, 
are  always  the  cause  of  clefts  of  the  palate. 

One  would  hesitate  to  question  the  deductions  from  such  careful 
and  extensive  observations  if  there  was  not  such  overwhelming  contra- 
evidence.  Warnekros  does  not  seem  to  take  into  consideration  the  re- 
lation of  palate  clefts  to  extensive  cranial  clefts,  defects  of  the  brain, 
facial  clefts,  and  other  deformities  that  can  have  no  connection  with  the 
teeth,  nor  does  he  seem  to  offer  evidence  that  the  formation  of  the  teeth 
antedates  the  normal  closure  of  the  palate  clefts. 

The  labiodental  strand,  or  dental  ledge,  from  which  the  teeth  are 
formed,  appears  about  the  beginning  of  the  seventh  week.  About  the 
ninth  fetal  week,  according  to  Rose,  elevations  appear  on  the  free  bor- 
der of  this  ledge  which  mark  the  enamel  organs  of  the  milk  teeth. 

Whatever  influence  supernumerary  teeth  might  have  must  be  ex- 
erted before  the  time  for  closure  of  the  alveolar  part  of  the  fissure, 
which,  according  to  Zukerkandl,  takes  place  at  a  period  considerably 
earlier  than  the  ninth  week,  and  the  ninth  week  is  the  time  when  the 
dental  ledge  first  shows  indications  of  separate  tooth  papillae. 

That  supernumerary  teeth  can  be  present  in  the  absence  of  patent 
facial  clefts  is  well  known. 

Dr.  Warnekros  himself  quotes  from  G.  Kohne's  treatise  as  follows : 
"Through  tooth  germs  remaining  latent,  but  which  are  always  pres- 


CONGENITAL  FACIAL  CLEFTS.  167 

ent,  there  are  developed  in  individual  cases,  ovi^ing  to  atavism,  enamel- 
less  tooth  peglets,  peg  teeth,  and  also  quite  normally  formed  teeth 
which  remain  hidden  in  the  maxilla."  Zukerkandl  found  enamelless 
tooth  rudiments  in  the  region  of  the  incisor  teeth  in  20  out  of  630 
crania. 

Maternal  Impressions. — The  possible  influences  on  the  vital 
processes  that  could  cause  failure  of  cohesion  of  the  cleft  borders  are 
probably  numerous,  but  to  be  effective  they  must  act  before  the  time 
when  the  clefts  normally  close.  One  of  the  oldest  theories  in  this  re- 
gard is  that  of  relation  to  rnaternal  impressions.  While  it  is  unwise 
to  absolutely  deny  the  possibility  of  such  a  cause,  still  there  is  little  ma- 
terial evidence  to  support  this  view.  Our  experience,  like  that  of  most 
other  observers,  has  been  that  in  every  instance  the  supposed  maternal 
impression  occurred  after  the  time  of  normal  closure  of  the  clefts. 

Malnutrition. — Another  supposedly  possible  influence,  and  one 
that  cannot  be  so  quickly  disposed  of,  is  malnutrition.  It  is  a  matter 
of  common  observation  that  cleft  palate  and  lip  occur  much  more  fre- 
quently among  the  lower  and  more  ignorant  classes,  and  apparently 
among  those  whose  hygienic  surroundings  are  poor.  Among  our  cases, 
especially  those  occurring  in  families  of  the  better  classes,  it  has  been 
a  frequent  observation  that  the  mother,  early  in  pregnancy,  suffered  ex- 
cessively from  nausea,  or  was  in  poor  nervous  condition. 

It  has  been  our  observation  that  the  occurrence  of  cleft  palate  in  the 
negro  is  infrequent,  but  one  such  case  having  come  to  our  notice.  It 
is  supposed  that  it  is  almost  unknown  among  the  aborigines  of  the  Pa- 
cific islands.  But  Mr.  Henry  George,  late  technician  of  the  Hunterian 
Museum,  showed  me  a  skull  with  a  cleft  palate  that  is  supposed  to  be 
of  a  Polynesian. 

The  observations  cited  above  can  be  considered  as  but  little  more 
than  suggestive,  and  we  do  not  believe  that  we  are  in  a  position  to  state 
that  cleft  palate  is  dependent  upon  poor  hygiene.  There  is  one  sup- 
posed occurrence  which,  if  true,  would  have  been  of  definite  value.  It 
has  been  repeatedly  stated  that  in  the  London  Zoo,  when  pregnant 
lionesses  were  fed  on  meat  containing  bones  too  large  to  be  chewed, 
the  cubs  often  appeared  with  palate  clefts,  but  when  the  mothers  were 
fed  on  meat  containing  small  or  soft  bones,  the  cubs  were  normal. 
This  was  advanced  to  support  the  theory  that  clefts  might  be  dependent 
upon  lack  of  proper  nourishment.  In  discussing  the  subject,  Mr.  Ar- 
thur Keith,  who  is  an  officer  of  the  London  Zoological  Gardens,  in- 
formed the  author  that  it  was  true  that  lion  cubs  born  in  the  gardens 
frequently  had  cleft  palate,  but  that  careful  experimentation  both  with 
the  food  and  water  failed  to  show  any  relation  between  the  mother's 
food  and  the  occurrence  of  the  defect. 


168 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Injury  and  Infection. — It  is  probable  that  both  injury  and  dis- 
ease may  influence  the  closure  of  these  clefts.  While  we  are  not  as 
yet  prepared  to  furnish  anything  like  exact  percentages,  we  have  been 
impressed  with  the  proportion  of  cleft  palate  patients  that  have  shown 
signs  suggestive  of  syphilis.  In  the  majority  of  infants  in  whom  we 
have  had  the  conjunctiva  examined  with  the  Gzapski-Luedde  pattern  of 
the  Zeiss  Binocular  Corneal  Microscope,  there  have  been  observed 
aneurysmal  dilatation  and  thickening  of  the  blood  vessels.  The  technique 
of  the  examination  requires  an  anesthetic,  and  we  have  not  as  yet  made 
a  sufficient  number  of  them  to  be  of  value.  Many  children  thus  af- 
flicted show  the  Graves  scaphoid  scapula,  which  we  believe  bears  a 
relation  to  congenital  syphilis.  So  far,  Wassermann  tests  have  not  been 
satisfactory  in  settling  the  question,   for  they  have  almost  invariably 


Fig.   104.     Incomplete    cleft    of   the    lip    with    a    depressed    groove    running    up    to 
spread  nostril  on  that  side. 


proved  negative,  even  in  patients  who  showed  facial  contour  and  other 
signs  that  are  considered  typical  of  congenital  syphilis.  One  child,  in 
whom  the  Wassermann  was  repeatedly  negative,  later  developed  active 
tertiary  syphilis  with  positive  Wassermann.  Biondi  suggested  that 
atrophy  of  the  edges  of  the  cleft,  due  to  inflammation,  might  prevent 
closure,  and  we  are  inclined  to  accept  syphilis  as  one  of  the  possible 
causes  of  such  an  inflammation. 

In  reference  to  injuries  and  ordinary  infections,  Moll  has  made  a 
careful  study  of  a  large  number  of  products  of  early  abortions.  He 
found  in  many  cases  evidences  of  infection  and  of  faulty  development. 
It  is  his  conclusion  that  monsters  and  deformed  infants  may  result  from 
intrauterine  injuries  and  infections  that  were  not  sufficiently  severe  to 
cause  the  immediate  death  of  the  fetus. 

Mr.  Keith  has  shown,  from  au  examination  of  the  material  in  the 


CONGENITAL  FACIAL  CLEFTS. 


169 


various  London  medical  museums,  that  cleft  of  the  palate  is  rather  com- 
mon in  monsters. 

No  explanation  has  ever  been  offered  for  the  fact  that  palate  and 
lip  clefts  appear  on  the  left  side  twice  as  often  as  on  the  right.  It  is 
a  common  observation  that  lips  and  palates  which  are  not  actually  cleft 
or  which  may  be  cleft  in  only  a  part  of  their  extent  may  show  a  dis- 
tinct line  of  irregular  union  that  resembles  a  scar  (Fig.  104).  It  may 
be  accompanied  by  the  broadening  of  the  nostril  and  flattening  of  the 
ala  that  are  t3'pical  of  complete  harelip.  These  are  not  true  scars,  for 
they  show  no  scar  tissue ;  nor  do  they  ever  contain  mucous  membrane 
with  which  all  true  lip  clefts  are  edged.  Trendelenburg  regards  them 
as  an  incomplete  union,  and  they  are  to  be  compared  with  the  median 
raphe  of  the  scrotum  and  perineum. 

CONGENITAL  LIP  PITS. 

A  peculiar  and  rare  facial  deformity,  which  is,  as  far  as  we  know, 
not  directly  related  to  the  embryonal  clefts,  but  which,  when  it  has  oc- 


Fig.  105.  Congenital  lip  pits  in  a  girl  who  had  a  clclt  i)alat(\  There  were  several 
instances  of  open  clefts  in  her  family,  and  her  brother  had  a  cleft  palate  with  similar 
lip  pits.  In  both  instances  the  pits  were  dry,  but  cases  have  occurred  in  which  the  pits 
gave  forth  a  mucous  secretion. 

curred,  has  usually  been  in  conjunction  with  patent  clefts,  is  lateral 
pits  in  the  lower  lip  (Fig.  105).  There  may  be  slight  depressions  or 
deep  pits,  situated  in  fleshy  teats  from  which  fluid  exudes.  The  fact 
that  they  are  observed  to  occur  in  connection  with  double  harelip  gave 
rise  to  the  idea  that  the  lip  cleft  was  in  some  way  responsible  for  the 
pit  and  teat ;  but  in  the  specimen  shown  there  was  no  harelip,  but  there 
was  a  cleft  palate.  Mr.  Arthur  Keith,  who  has  studied  the  subject, 
finds  that  the  nearest  explanation  he  can  give  for  the  occurrence  of  lip 
pits  in  the  human  is :  a  possible  reversion  to  the  mucous  glands  which 
are  normally  found  in  the  lip  of  the  shark. 


CHAPTER  XII. 

CONGENITAL  PALATE  CLEFTS— PRINCIPLES  OF 
REPAIR  BY  PLASTIC  FLAPS. 

In  every  case  of  congenital  cleft  of  the  palate  situated  behind  the 
incisive  foramen,  regardless  of  whatever  auxiliary  means  may  be 
adopted,  the  final  closure  is  done  by  bridging  the  deficit  with  flaps  made 
from  the  soft  tissue.  Further,  whether  the  operation  is  done  on  a 
young  infant,  a  child,  or  an  adult,  except  in  certain  extraordinary  cases, 
the  same  general  plan  of  operation  is  applicable  in  all  cases. 

This  chapter  will  deal  with :  first,  the  general  consideration  of  the 
construction  of  flaps  from  the  palate  tissues ;  and  second,  of  flaps  from 
extrapalatal  sources. 

The  success  of  any  operation  or  mechanical  appliance  for  the  res- 
toration of  the  palate  is  mainly  in  proportion  to  its  success  in  restoring 
or  taking  on  the  function  of  the  velum.  A  velum  that  is  too  short  is 
but  a  poor  substitute  for  the  normal  condition. 

ANATOMICAL  CONSIDERATIONS. 

The  hard  and  soft  palate  together  are  collectively  termed  the  palate, 
which  is  covered  on  both  surfaces  by  mucous  membrane  and  submucous 
tissue,  etc.  At  the  outer  border  of  the  hard  palate,  close  to  the  alveolar 
process,  and  at  the  level  of  the  posterior  border  of  the  last  molar  tooth 
is  the  opening  of  the  posterior  palatine  canal,  through  which  the  de- 
scending palatine  artery  and  large  posterior  palatine  nerve  emerge 
to  enter  the  palate  tissues.  Other  smaller  palate  nerves  emerge  from 
accessory  foramina  situated  behind  the  opening  of  the  posterior  palatine 
canal  (Fig.  7).  Anteriorily,  at  the  incisive  foramen  the  nasopalatine 
nerve  emerges  with  some  terminal  branches  of  the  vessels  of  the  nasal 
septum.  In  cases  of  double  cleft  palate,  the  distribution  of  these  latter 
is  confined  to  the  intermaxillary  bone.  The  maxillary  tubercle  is  the 
prominence  at  the  posterior  end  of  the  superior  alveolar  process.  Be- 
hind and  slightly  internal  to  this  tubercle  can  be  felt  the  tip  of  the 
hamular  process  of  the  internal  plate  of  the  pterygoid  process  of  the 
sphenoid  bone.  About  1  centimeter  behind  the  hamular  process  the 
ascending  palatine  artery  enters  the  velum  subjacent  to  its  oral  mucous 
membrane. 

The  velum  is  intimately  attached  to  the  hard  palate,  not  only  by 
the  palate  aponeurosis,  but  by  the  continuity  of  its  mucous  coverings. 

170 


CONGENITAL  PALATE  CLEFTS.  171 

Besides  the  azygos  uvulae  muscle,  which  occupies  a  median  position, 
and  portions  of  the  palatoglossi  and  palatopharyngei,  which  form  the 
anterior  and  posterior  faucial  pillars,  the  soft  palate  contains  the  termi- 
nations of  the  levator  palati  and  tensor  palati  muscles.  These  latter, 
after  arising  from  the  base  of  the  skull  and  skirting  the  lateral  wall 
of  the  nasopharynx,  enter  the  velum  above  the  upper  border  of  the  su- 
perior constrictor  muscle  (Fig.  106).  In  the  velum  the  contained  mus- 
cles are  intimately  connected  with  the  palate  aponeurosis.  The  tensor 
palati  descends  between  the  external  and  internal  pterygoid  plates  and 
is  separated  by  the  latter  from  the  mucous  lining  of  the  nasopharynx. 
At  the  apex  of  the  internal  pterygoid  plate  its  tendon  turns  at  a  right 
angle  over  the  hamular  process,  which  serves  it  as  a  pulley,  and  then 


Fig.  106.  Palate  muscles.  Essential  palate  niuscles  viewed  from  behiud.  A,  leva- 
tor palati  muscle ;  B,  tensor  palati  muscle ;  C,  palatoglossus  muscle  ;  D,  tendon  of  the 
tensor  palati  muscle  ;  E,  hamular  processes  ;  F,  bursa  ;   G,  tensor  palati  muscle. 


spreads  out  in  the  substance  of  the  velum.  Its  motor  nerve  supply, 
which  is  from  the  fifth  cranial,  enters  its  posterior  border  and  is  well 
out  of  danger  from  cutting  during  a  palate  operation. 

The  levator  palati  muscle  is  situated  behind  the  tensor,  separated 
from  the  latter  at  its  origin  by  the  pharyngeal  end  of  the  Eustachian 
tube.  As  this  muscle  descends  to  enter  the  velum,  it  approaches  the 
mesial  plane  and  lies  directly  subjacent  to  the  submucous  tissue  of  the 
nasopharynx.  Strange  as  it  may  seem,  the  motor  nerve  supply  of  the 
levator  palati  muscle  is  a  matter  of  uncertainty.  Most  anatomists  be- 
lieve that  it  is  innervated  by  the  eleventh  cranial  through  the  pharyngeal 
plexus,  while  Spalteholz,  Merkel,  and  some  others  maintain  that  it 
comes  from  the  fifth  cranial  through  a  branch  that  passes  back  from 
the  large  posterior  palatine  nerve  just  after  it  enters  the  palate  from 


172 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  posterior  palatine  canal.  This  lack  of  exact  knowledge  is  unfor- 
tunate, since  the  preservation  of  the  nerve  supply  of  these  muscles  con- 
serves good  functional  success  of  the  operation.  Our  own  dissections 
and  observations,  made  after  various  complicated  palate  operations,  lead 
us  to  the  belief  that,  with  but  few  possible  exceptions,  operations  for 
all  cases  can  be  so  planned  as  to  avoid  injury  to  the  nerve  of  this  mus- 
cle, regardless  of  which  course  it  really  pursues. 

The  soft  tissues  covering  the  hard  palate  consist  of  the  mucous 
membrane,  the  submucous  tissue  containing  lymph  follicles,  blood  ves- 
sels, and  nerves,  and  the  periosteum.  These  are  all  fused  together  into 
a  rather  inseparable  layer,  but  the  whole  is  easily  detached  from  the 
bone. 

In  front  and  laterally  as  far  back  as  the  maxillary  tubercle,  in  the 
edentulous  mouth,  the  soft  tissues  of  the  palate  are  continuous  through 


Fig.    107. 


Fig.    108. 


Fig.   107.      Diagram    of   coronal   section   through    a   double    cleft   of   the    palate. 
Fig.   108.     'Diagram   of   a   coronal   section   through   a  single  cleft  of  the   palate. 


the  gums  with  the  mucous  lining  of  the  vestibule.  Where  the  teeth 
are  in  place,  this  continuity  is  carried  on  through  the  interdental  por- 
tion of  the  gingivae. 

In  a  double  cleft,  the  mucous  tissues  of  the  roof  of  the  mouth  are 
continuous  with  those  of  the  floor  of  the  nose  and  nasopharynx  on  both 
sides,  while  the  nasal  septum,  attached  anteriorly  to  the  intermaxillary 
process,  stands  free  in  the  cleft  (Fig.  107).  The  nasal  and  oral  blood 
vessels  anastomose  freely  around  the  borders  of  the  cleft. 

In  a  single  complete  cleft,  the  mucous  membrane  and  submucous 
tissues  lining  the  roof  of  the  mouth  are  continuous  around  one  cleft 
border  with  the  mucous  membrane  and  submucous  tissues  on  the  upper 
surface  of  the  palate  process  and  velum,  and  at  the  other  border  with 
the  mucous  membrane  and  submucous  tissues  of  the  upper  surface  of 
the  velum  posteriorly,  and  of  the  lateral  surface  of  the  nasal  septum 
anteriorly  (Fig.  lOS). 


CONGENITAL  PALATE  CLEFTS. 


173 


FLAPS  MADE  FROM  PALATE  TISSUES. 

From  the  anatomical  points  just  considered,  it  will  be  seen  that 
flaps  of  soft  tissue  for  the  repair  of  congenital  palate  defects  may, 
broadly  speaking,  be  made  in  three  different  ways : 

(a)  The  border  of  the  cleft  may  be  taken  as  the  base  of  the  flap, 
with  the  blood  supply  coming  through  the  anastomosis  with  the  nasal 
vessels  (Figs.  130  and  131).  If  there  are  no  intervening  teeth  in  the 
alveolar  arch  to  interfere,  such  a  flap  may  include  the  palate  tissues,  the 
gum,  and  even  part  of  the  cheek.  Such  a  flap  can  be  rotated  until  the 
raw  surface  is  toward  the  mouth  and  the  mucous  surface  is  toward  the 
nasal  fossa.  With  care  this  flap  can  often  be  raised  sufficiently  without 
cutting  either  the  posterior  palatine  nerve  or  the  descending  palatine 
artery,  which  latter  will  absolutely  insure  its  blood  supply.  Such  a  flap 
can  be  turned  from  the  upper  surface  of  the  velum  (Fig.  133). 


Pig.  109.  Diagram  illustrating  a  palate  flap  in  which  the  velum  has  been  detached 
from  the  palate  process  by  cutting  through  the  palate  aponeurosis  and  mucous  mem- 
brane at  a. 


(b)  A  flap  can  be  raised  with  a  narrow  pedicle  directed  toward  the 
termination  of  the  posterior  palatine  canal,  to  be  nourished  by  branches 
from  the  descending  palatine  artery  (Fig.  134  and  135).  This  flap  may 
be  cut  to  include  the  tissues  covering  the  hard  palate,  or  may  be  taken 
from  the  velum,  or  even  from  the  cheek  and  gum.  Flaps  of  the  (a) 
and  (b)  varieties  were  first  popularized  in  the  Davies-Colley  operation. 
The  (a)  flaps  are  used  in  conjunction  with  both  (b)  and  (c)  by  Lane 
in  his  operations. 

(c)  A  flap  may  be  formed  by  incising  the  mucoperiosteum  at  the 
border  of  the  cleft  and  raising  the  soft  tissues  from  the  under  surface 
of  the  bone  as  far  laterally  as  the  alveolar  process.  If  there  are  no 
teeth  intervening,  the  gum  and  even  a  part  of  the  cheek  may  be  in- 
cluded (Figs.  130  and  131).  When  this  has  been  done,  the  flap  will  be 
still  bound  to  the  bone  at  the  posterior  border  of  the  palate  process,  and 
to  free  it  here,  it  is  necessary  to  cut  the  nasal  mucous  membrane  and 
palate  aponeurosis  along  this  line   (Fig.  152).     When  these  are  sev- 


174 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


ered,  the  velum  and  the  mucoperiosteum  of  the  palate  are  converted 
into  one  continuous  flap  (Fig.  109). 

The  fashioning  of  the  last-described  flap  may  be  modified  in  sev-  . 
eral  ways.  An  incision  may  be  made  along  the  nasal  surface  of  the 
palate  process,  and  part  of  the  mucous  and  submucous  tissues  of  this 
surface  included  in  the  flap  that  is  raised  from  the  oral  surface  of  the 
palate  process.  On  one  side  of  a  single  cleft  a  large  piece  of  muco- 
periosteum may  be  loosened  from  the  nasal  septum  and  included  in  the 
flap  (Fig.  110).  The  former  method  is  to  be  utilized  in  cases  of  wide 
double  cleft,  and  the  latter  in  cases  of  wide  single  cleft. 

Flaps  fashioned  after  the  manner  described  under  (c)  are  those 
most  commonly  used,  and  are  the  ones  employed  in  the  classic  opera- 
tion, which  for  convenience  may  be  termed  the  von  Langenbeck  op- 
eration.    Such  flaps  are  in  many  ways  superior  to  those  described  as 


Fig.  110.  Diagrammatic  coronal  section  through  a  single  cleft  of  the  palate.  Illus- 
trating :  a,  how  part  of  the  coverings  of  the  nasal  septum  may  be  included  with  a 
palate  flap  ;  b,  how  part  of  the  covering  of  the  floor  of  the  nose  may  be  included  with  a 
palate  flap. 


(a)  and  (b).  If  properly  made,  the  blood  supply  is  nearly  always 
good,  and  sloughing  of  the  flap  eii  masse  is  extremely  rare.  If  there  is 
failure  of  union,  in  part  or  throughout  the  suture  line,  the  flaps  simply 
drop  back  to  their  bed  and  adhere  in  their  original  positions  and  shape. 
On  the  other  hand,  sloughing,  in  part  or  in  toto,  of  flaps  made  as  de- 
scribed under  (a)  and  (b)  is  not  at  all  rare,  and  when  a  slough  occurs 
in  a  large  part  of  a  flap,  it  may  be  very  difficult  to  find  tissues  to  replace 
it  at  a  second  operation.  With  (a)  and  (b)  flaps,  even  failure  of  union 
of  the  suture  line  is  disastrous;  for  the  flap  rotated  from  its  original 
bed  is,  in  case  of  failure  of  union,  left  without  sufficient  support,  and  ii 
shrinks  and  becomes  distorted  by  the  contraction  of  the  granulations 
on  its  raw  surface. 

If  a  (b)  or  a  (c)  flap  on  one  side  is  used  in  combination  with  an 
(a)  flap  on  the  other  side  of  the  cleft,  broad  raw  surfaces  may  be 
brought  into  apposition  (Figs.  130  and  132).  The  apparant  advantage 


CONGENITAL  PALATE  CLEFTS. 


175 


of  this  is  more  than  outweighed  by  certain  disadvantages  that  are  inher- 
ent to  this  method.  It  requires  more  handhng  of  the  tissues,  which,  with 
the  double  row  of  sutures,  predisposes  to  suppuration  and  even  throm- 
bosis. Failure  of  union  or  loss  of  tissue  renders  second  operation  very 
difficult,  and  not  the  least  consideration  is  the  fact  that  it  requires  more 
time  and  is  more  difficult  to  make  the  (a)  or  (b)  flaps. 

Warren,  of  Boston,  and  von  Langenbeck,  the  great  Berlin  surgeon, 
proposed  operations  for  the  correction  of  congenital  clefts  of  the  pal- 
ate, which  consisted  essentially  of  loosening  mucoperiosteal  flaps  from 
the  hard  palate  and  liberating  the  velum,  and  then  suturing  the  denuded 
median  borders  of  the  flaps  across  the  defect. 

Their  ideas  are  crystallized  in  what  has  come  down  to  us  as  the 
von  Langenbeck  operation,  which  employs  only  the  (c)  flaps.  On  ac- 
count of  the  conformation  of  the  bony  palate,  the  (c)  flaps  usually  fur- 
nish sufficient  tissue  to  close  even  wide  defects. 


Fig.  111.  Diagram  illustrating  how  the  flaps  taken  from  an  incomplete  palate  arch 
together  may  be  of  sufficient  width  to  reach  across  from  one  side  of  the  base  of  the  arch 
to  the  other. 


The  cleft  palate  is  an  incomplete  Gothic  arch.  When  the  muco- 
periosteum  of  each  side  is  incised  at  the  borders  of  the  cleft  and  the 
flap  freed  from  the  bone,  which  forms  the  sides  of  the  incomplete  arch, 
they  can  be  brought  straight  across  from  one  side  of  the  base  of  the 
arch  to  the  other  (Fig.  111).  If  there  is  any  deficiency  opposite  the 
junction  of  the  hard  palate  and  velum,  this  is  usually  compensated  for 
by  the  lateral  incisions  (Fig.  159),  which  do  not  interfere  with  the 
blood  supply  and  allow  considerable  relaxation  of  the  flap. 

The  reconstructed  palate,  made  with  von  Langenbeck  flaps,  is  flat 
from  side  to  side  and  may  present  wide  gaps  at  the  site  of  the  lateral 
incisions.  As  healing  progresses,  however,  the  flap  is  drawn  snugly 
up  to  the  bone,  and  the  edges  of  the  lateral  incisions  are  gradually  ap- 
proximated until,  in  time,  the  only  abnormality  that  may  be  observed 
on  inspection  is  the  longitudinal  scar  in  the  midline.  If,  as  should  be 
the  case,  the  periosteum  is  included  in  the  flap,  true  bone  is  commonly 
reproduced  at  the  site  of  the  cleft,  so  that  ultimately  the  bony  arch  may 
be  completely  restored. 


176  SURGERY  OF  THE  MOUTH   AND  JAWS. 

FLAPS  MADE  FROM  OTHER  THAN  PALATE  TISSUES. 

Flaps  made  from  the  nasal  septum  and  from  the  floor  of  the  nose 
are,  strictly  speaking,  extrapalatal  flaps,  but  for  convenience  these  were 
included  with  flaps  made  from  the  palate  tissues. 

Extrapalatal  flaps  may  be  derived  from  intraoral  and  extraoral 
sources.  Intraoral  flaps  are  covered  with  mucous  membrane,  while 
the  extraoral  flaps  include  the  skin.  The  former  are  usually  derived 
from  the  inner  surface  of  the  cheek  or  the  gums,  though  sometimes  the 
tongue  or  pharyngeal  wall  has  been  pressed  into  service.  The  latter 
plan  was  first  devised  by  Passavant.  Von  Mosetig-Moorhof  went  to 
the  trouble  of  supplementing  the  velum  with  a  flap  turned  from  the 
posterior  wall  of  the  oral  pharynx,  and  then  cut  a  hole  in  the  hard  pal- 
ate to  allow  of  nasal  respiration.  In  the  edentulous  mouth  varying 
amounts  of  gum  and  cheek  may  be  included  with  the  palate  flaps. 
When  teeth  are  present,  a  buccal  flap  can  advantageously  be  turned  on 
to  the  palate,  only  behind  the  molar  teeth  or  in  front  at  the  site  of  an 
alveolar  cleft.  When  the  normal  mouth  is  opened  to  its  widest  extent, 
the  limit  to  further  excursion  of  the  mandible  is  in  the  joint  and  not 
in  the  cheek,  which  can  still  be  felt  to  be  flaccid.  Fairly  generous  flaps 
can  be  constructed  from  the  mucous  lining  and  buccinator  muscle  with- 
out inconveniencing  the  patient.  The  motor  nerve  supply  of  the  mus- 
cle is  from  the  seventh  cranial,  which  comes  from  behind  and  around 
the  outer  surface  of  the  masseter  muscle  (Fig.  213).  The  opening  of 
the  parotid  duct  is  opposite  the  second  upper  molar  tooth,  and  the  blood 
supply  of  the  cheek  is  everywhere  good. 

A  flap  that  has  its  base  at  the  upper  lip  can  be  taken  from  above 
and  in  front  of  the  opening  of  the  duct  and  utilized  in  closing  an 
alveolar  cleft  or  a  defect  in  the  anterior  part  of  the  hard  palate. 

The  posterior  end  of  the  buccinator  muscle  is  attached  to  almost 
the  full  length  of  the  pterygomaxillary  ligament,  while  posteriorly  the 
ligament  gives  origin  to  a  like  amount  of  the  superior  constrictor  mus- 
cle of  the  pharynx  (Fig.  7).  The  ligament  itself  extends  from  the 
tip  of  the  pterygoid  process  of  the  sphenoid  to  the  inner  surface  of 
the  body  of  the  mandible  and  rests  on  the  anterior  part  of  the  in- 
ternal pterygoid  muscle.  The  adjacent  portion  of  the  buccinator  mus- 
cle rests  on  the  inner  surface  of  the  masseter  muscle,  while  the  adja- 
cent part  of  the  superior  constrictor  muscle  of  the  pharynx  bears  a  sim- 
ilar relation  to  the  internal  pterygoid  muscle. 

Flaps  which  include  the  pterygomaxillary  ligament,  the  anterior 
part  of  the  superior  constrictor  of  the  pharynx,  and  the  posterior  part 
of  the  buccinator  with  their  mucous  coverings,  may  be  satisfactoril) 
and  safely  made  according  to  either  of  the  plans  shown  in  Figs.  163 
and  164,  or  175  and  176. 


CONGENITAL  PALATE  CLEFTS. 


177 


The  cutting  of  the  pterygomaxillary  Hgament  cannot  interfere  with 
the  action  of  tl'ie  upper  part  of  the  superior  constrictor  muscle  of  the 
pharynx  in  the  formation  of  Passavant's  pad,  because  the  fibers  that, 
by  their  contraction,  produce  this  eminence  are  the  pterygopharyngeus, 
and  the  part  of  the  superior  constrictor  that  arises  directly  from  the 
pterygoid  process.  The  lower  fibers  of  the  muscle  are  but  temporarily 
crippled  by  cutting  the  pterygomaxillary  ligament. 

A  piece  has  been  stripped  from  the  edge  of  the  tongue  and  stitched 
into  a  palate  defect.  The  tongue  has  been  split  longitudinally  at  its 
lateral  border  and  incorporated  into  the  palate.  In  both  of  these  in- 
stances the  mass  of  the  tongue  is  later  cut  free  from  the  palate. 

Marshall  illustrates  a  case  of  Rotter's,  in  which  he  turned  a  vertical 
flap  from  the  middle  of  the  forehead  and  bridge  of  the  nose  and,  after 


Fig.  112.  Diagram  illustrating  a  flap  (AAA),  which  has  been  i-aised  from  the  side 
of  the  neck  and  still  attached  to  the  cheek  (B),  can  be  brought  through  an  incision  in 
the  lower  buccal  fornix  and  laid  in  a  palate  defect.  It  can  be  seen  that  this  flap  could 
be  used  for  lining  a  cheek,  instead  of  a  palate  defect. 


grafting  its  raw  surface  with  Thiersch  grafts,  left  it  in  its  original  po- 
sition until  the  grafts  had  taken.  Later  he  turned  the  flap  into  the  pal- 
ate cleft  through  an  incision  made  at  the  side  of  the  nose  and  sutured 
it  into  the  cleft,  the  tissues  of  the  face  being  drawn  together  with  su- 
tures to  efface  the  defect.  He  mentions  that  Blasius  was  the  first  to 
use  extrapalatal  flaps,  and  that  Thiersch  had  done  so  in  a  second  case. 
We  believe  that  the  most  available  extraoral  tissue  is  to  be  obtained 
from  the  neck.  A  long  narrow  flap  of  tissue  can  be  raised  from  the 
side  of  the  neck  with  its  base  at  the  lower  border  of  the  mandible.  It 
should  include  the  skin,  superficial  fascia,  and  platysma  myoides  mus- 
cle. As  soon  as  the  flap  is  liberated,  the  neck  defect  can  be  immedi- 
ately effaced  by  drawing  the  edges  of  the  wound  together  with  sutures. 
The  superficial  tissues  of  the  neck  are  usually  very  redundant,  and  the 
approximation  can  be  further  facilitated  by  undermining  between  the 


178  SURGERY  OF  THE  MOUTH  AND  JAWS. 

platysma  muscle  and  the  deep  fascia.  Still  further  relaxation  can  be 
obtained  by  making  an  incision  at  the  base  of  the  neck  parallel  to  the 
original  wound  and  well  to  its  outer  side;  this  wound  also  serves  for 
drainage.  This  flap  is  made  5  centimeters  wide,  and  its  length  will 
depend  on  the  sex  of  the  patient.  In  a  girl  the  tissue  from  the  neck 
may  be  used,  but  in  a  boy  or  a  man  the  flap  must  include  the  tissue  of 
the  upper  part  of  the  neck  to  well  below  the  clavicle,  as  only  the  lower 
end  of  the  flap  will  be  free  from  hair.  Through  an  incision  in  the  bot- 
tom of  the  buccoalveolar  cul-de-sac  the  flap  is  turned  into  the  mouth 
and  sutured  into  the  palate,  the  jaws  being  temporarily  held  apart  with 
an  intraoral  gag.  Later  the  pedicle  of  the  flap  is  cut,  and  the  upper 
end  of  the  neck  wound  repaired  (Fig.  112).  (For  further  details  of 
turning  flaps  from  the  neck  see  Chap.  XVI,  Figs.  177,  178,  179,  and 
ISO,  and  Chap.  XIX,  Figs.  218,  220,  221,  and  222.) 


CHAPTER  XIII. 

CONGENITAL  CLEFTS  OF  THE  PALATE  AND  LIP- 
PREFERABLE  AGE  AT  WHICH  TO  OPERATE. 

In  the  determination  of  the  time  at  which  operations  for  closure  of 
clefts  of  the  hard  palate  ought  best  to  be  done,  two  considerations  con- 
front us :  the  ideal,  and  the  surgically  probable. 

CONSIDERATION  OF  VARIOUS  AGES. 

It  was  the  belief  of  the  older  surgeons,  the  pioneers  in  this  work, 
that  the  probability  of  surgical  success  is  greatest  when  the  cleft  is  rela- 
tively small  and  the  soft  tissues,  from  which  the  obturator  is  to  be 
made,  are  comparatively  well  developed. 

At  Twelve  Years. — At  the  age  of  twelve  or  fifteen  we  still  have 
the  excessive  nutrition  of  growing  tissue,  the  alveolus  is  well  devel- 
oped, the  arch  of  the  palate  is  high,  and  there  is,  relatively,  a  large 
amount  of  tissue  in  proportion  to  the  cleft  to  be  bridged.  Further,  it 
was  supposed  that  by  this  time  the  intelligence  of  the  patient  and  the 
desire  for  relief  from  the  deformity  would  materially  aid  in  obtaining 
the  desired  result.  It  was  for  these  reasons  that  the  older  surgeons 
chose  this  age  as  the  time  of  election. 

Unfortunately,  though  the  probability  of  obtaining  a  surgical  result 
at  this  age  be  great,  the  result  obtained  is  at  best  relative.  The  naso- 
pharynx, nasal  cavities,  and  the  tongue  of  one  so  afflicted  develop  ab- 
normally, and  where  speech  has  been  attempted  with  a  cleft  palate, 
the  imperfect  enunciation  that  results  is  but  partially  corrected  by  a 
later  restoration  of  the  roof  of  the  mouth  and  the  velum. 

At  Two  Years. — The  "cleft  palate  speech"  is  a  stigma  that 
usually  outlasts  the  most  perfect  late  operation.  This  has  caused  more 
recent  operators  to  seek  an  earlier  period  for  repair,  and  by  a  number 
the  age  of  two  has  been  pronounced  as  ideal,  because  there  is  at  this 
time  a  fair  development  of  the  mucoperiosteal  covering  of  the  bone 
with  considerable  arching  of  the  palate  due  to  the  alveolar  process,  and 
because  it  is  possible  to  narrow  the  cleft  by  orthodontic  apparatus. 
Further,  at  this  age  the  child's  speech  is  but  imperfectly  developed; 
therefore  the  cleft  palate  habit  is  not  fully  formed,  and  successful  opera- 
tions at  this  age  give  excellent  voice  results. 

In  Early  Infancy. — Still  other  operators,  impressed  with  the 
fact  that  at  birth  there  was  simply  the  cleft,  though  relatively  wide,  and 

179 


180 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


that  all  the  structures  were  normally  developed,  and  that  the  longer 
growth  went  on  with  an  open  palate  the  farther  these  structures  re- 
ceded from  the  normal,  sought  a  still  earlier  age  for  surgical  interfer- 
ence. Close  study  of  the  subject  showed  that,  besides  better  after  re- 
sults, the  very  early  ages  presented  surgical  advantages  that  had  been 
at  first  overlooked.  Certain  of  these  advantages  refer  to  the  local  con- 
ditions, while  others  concern  the  general  condition  of  the  patient. 

ADVANTAGES  OF  VERY  EARLY  OPERATION. 

Of  the  local  conditions  that  lend  themselves  in  early  operations, 
there  are  two :  First,  the  absence  of  teeth  and  the  lack  of  pronounced 
development  of  the  alveolar  processes — these  make  it  very  easy  to  go 
any  distance  in  obtaining  flaps  of  any  size  for  the  closure.  Secondly, 
the  bones  are  soft  and  pliable  and  exceedingly  well  nourished,  which 
makes  it  possible  to  shift  bodily  the  separated  maxillae  and  approximate 


Fig.    113. 


Fig.    114. 


Fig.   11.3.      Single  complete  cleft  in  an  infant  twenty  hours  old. 
Fig.   11-4.      Same   infant   eight   days   later. 

the  normal  position.  The  first  of  these  has  been  taken  advantage  of 
by  an  English  school,  led  by  Lane;  and  the  second  operation  is  an 
American  development,  long  championed  by  Brophy. 

Without  going  into  a  discussion  of  the  relative  advantages  of  the 
two  methods,  we  want  to  call  attention  to  the  fact  that,  either  of  these 
operations  being  possible  and  both  presenting  high  probabilities  of  sur- 
gical success,  there  are  advantages  in  the  early  operation  that  decrease 
in  direct  proportion  as  the  age  of  the  unoperated  child  increases.  Based 
on  our  own  observation,  these  advantages  are : 

L  That  the  infant  of  twelve  or  twenty-four  hours  stands  the  shock 
of  operations  as  well  as  it  does  the  violence  to  which  it  is  subjected 
during  parturition,  and  that  this  resistance  to  shock  decreases  as  the 
age  of  the  infant  increases. 

IL  If  the  cleft  is  confined  to  the  lip  and  alveolus,  the  child  will  be 
in  a  condition  to  be  nursed  by  its  mother  when  it  is  five  days'  old.  It 
is  possible  in  most  cases  to  preserve  the  flow  of  the  mother's  milk  that 


CONGENITAL  CLEFTS  OF  PALATE  AND  LIP.  181 

long  by  artificial  means — not  a  breast  pump — which  gives  the  child  all 
the  immediate  and  late  advantages  that  are  derived  from  breast  milk. 

III.  This  very  early  repair  of  palate  and  lip  saves  the  parents  an 
immense  amount  of  heartache  and  chagrin  (Figs.  113  and  111). 

IV.  The  health  of  infants  is  always  better  after  than  before  the 
repair  of  the  cleft.  We  have  seen  a  number  of  impressive  instances  of 
this  fact,  but  the  old  observation — that  cleft  palate  infants  were  apt  to 
die  through  lack  of  development  in  other  parts — is  correct.  The  in- 
fants coming  under  our  observation  are  on  an  average  as  healthy  after 
early  operations  as  are  normal  infants. 

V.  A  normal  nasopharynx  and  a  normal  voice  are  assured  by  early 
operation. 

In  the  very  early  operations  the  ideal  and  the  surgically  possible 
meet,  except  that  we  must  exercise  some  discretion  about  avoiding  op- 
eration during  the  process  of  teething.  We  are  convinced  that  the 
longer  the  operation  is  deferred  the  less  advantage  is  to  be  gained 
from  it,  but  also  that  there  is  no  age  at  which,  with  appropriate  tech- 
nique, we  cannot  operate  with  advantage. 


CHAPTER  XIV. 

CONGENITAL  PALATE  AND  LIP  CLEFTS— OPERATIONS 
IN  EARLY  INFANCY. 

At  twenty-four  hours  is  the  earliest  we  have  operated  for  this  de- 
fect, but  judging  from  the  fact  that  young  animals,  upon  which  the 
experiment  has  been  made,  show  greater  resistance  to  shock  and  less 
susceptibility  to  pain  during  the  first  twenty-four  hours  of  life  than 
they  do  during  the  second,  we  believe  that  the  operation  should  be  per- 
formed as  soon  after  birth  as  possible. 

PREPARATION  FOR  OPERATION. 

The  healthy  infant  requires  no  preparation,  and  if  old  enough  to 
take  nourishment,  should  be  fed  within  two  hours  of  the  operation. 

Starved  infants  with  a  subnormal  temperature  should,  by  proper 
feeding,  oil  rubs,  etc.,  be  brought  into  relatively  good  condition.  In 
dispensary  practice  it  is  a  good  custom  to  take  such  debilitated  infants 
into  the  hospital  for  a  few  days  until  the  child  shows  signs  of  mending, 
and  then  to  send  it  home,  keeping  close  supervision  of  its  food  and 
care.  Usually  ten  days  or  two  weeks  is  sufficient  to  bring  the  child 
to  an  operable  condition.  At  least  in  summer,  it  is  not  wise  to  keep  an 
infant  in  the  hospital  any  longer  than  is  necessary. 

Special  nipples,  carrying  broad  obturators,  have  been  devised  to 
enable  such  infants  to  suck  from  a  bottle,  but  when  it  is  intended  to  do 
an  early  operation,  these  are  unnecessary,  as  the  infant  can  be  more 
quickly  and  more  accurately  fed  by  means  of  an  eye  dropper.  Some 
of  them,  with  complete  clefts  of  the  lip  and  palate,  can  do  very  well 
with  an  ordinary  nipple  and  bottle.^ 

In  the  presence  of  any  acute  contagious  disease,  the  operation 
should  be  postponed,  but  pus  infections  should  be  treated  by  appro- 
priate surgical  measures,  general  hygiene,  and  possibly  by  appropriate 
vaccines. 

At  the  time  of  operation  the  child  should  be  swathed  in  a  light  wool 
covering,  which  is  enveloped  in  a  sterile  towel.  The  eyes  and  head 
should  also  be  covered  with  a  sterile  towel  that  is  held  in  place  with 
an  artery  forceps  or  a  safety  pin.     The  child  should  be  given  only  suf- 


*The  normal  process  of  procuring  milk  from  the  mother's  breast  Is  not  one 
purely  of  sucking.  The  infant  takes  the  nipple  and  most  of  the  areola  Into  Its 
mouth,  and  while  it  sucks,  it  also  squeezes  the  breast  with  its  Jaws.  It  Is  only  the 
latter  part  of  the  Drocess  that  can  be  utilized  by  the  cleft  palate  baby. 

182 


CONGENITAL  PALATE  AND  LIP  CLEFTS. 


183 


ficient  anesthetic  to  prevent  him  from  crying  out,  and  that  by  an 
extremely  careful  anesthetist.  Some  form  of  a  Junker  apparatus  is 
most  convenient  for  this  purpose.  The  author  uses  ether  in  all  cases. 
The  light  should  be  good  and  preferably  daylight,  but  usually  arti- 
ficial light  and  head  mirror  are  more  available.  The  operation  may 
be  done  w^ith  the  child  lying  flat  upon  its  back,  but  v^e  prefer  to  have 
the  head  hanging  over  the  end  of  the  table,  resting  in  the  hands  of  an 
assistant,  or  to  have  the  patient  on  the  side  with  the  head  of  the  table 


Fig.   115.      Approximating   tlie   maxillae   by   througli-and-through   wires, 
placing  a  heavy  sillc  loop  through  one  maxilla  posteriorly. 


First   step. 


somewhat  lowered.  In  either  of  the  positions,  the  blood  tends  to  flow 
away  from  the  larynx. 

There  are  two  popular  methods  of  operating  on  the  cleft  in  early 
infancy,  which  are  radically  different  in  principle  and  execution.  They 
can  be  very  properly  designated  as  the  Brophy  and  the  Lane  operations 
respectively. 

In  the  case  of  a  single  cleft,  it  should  be  determined  at  the  time  of 
operation  that  the  nostril  on  the  cleft  side  is  patent  posteriorly;  this 
may  be  done  by  inserting  a  probe. 


184 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


BROPHY  OPERATION. 

According  to  Heitmiiller,  Velpeau  probably  first  suggested  the 
early  operation  for  cleft  palate.  Julius  Wolfif  recommended  that  the 
operation  be  done  as  early  as  possible. 

In  1861,  Dr.  Reeves,  on  examining  a  dead  infant  that  had  a  cleft 
palate,  observed  that  most  of  the  tissue  that  goes  to  make  up  the  normal 
palate  was  present  and  the  width  of  the  cleft  depended  upon  the  fact 
that  the  maxillary  bones  were  spread  apart.     He  suggested  the  pos- 


--a 


Fig.   116.     Approximating  the  maxillae  by  througli-and-tlirough  wires, 
placing  a  heavy  silk  loop  through  the  other  maxilla  posteriorly. 


Second  step, 


sibility  of  treating  the  deformity  by  approximating  the  separated  max- 
illae (Fig.  122). 

Dr.  Brophy,  of  Chicago,  later  devised  the  operation  that  made  this 
practical.  The  technique  that  we  have  evolved  differs  somewhat  from 
that  used  by  Dr.  Brophy  but,  in  principle,  is  the  same. 

The  operation  consists  of  passing  silver  wires  through  the  maxillary 
bones  from  one  buccoalveolar  cul-de-sac  to  the  other.  By  twisting  the 
wires  over  two  lead  plates  and  by  lateral  pressure  on  the  bones  and, 
when  needed,  by  cutting  the  outer  wall  of  the  orbit  through  a  very 
small  mucous  incision,  the  anterior  end  of  the  cleft  is  obliterated,  and 


CONGENITAL  PALATE  AND  LIP  CLEFTS. 


185 


the  posterior,  part  is  narrowed.  The  parts  of  the  maxillae  that  are 
brought  in  contact  should  be  denuded  to  the  bone.  If  it  is  thought  ex- 
pedient, a  mucoperiosteal  flap  can  be  raised  from  the  hard  palate  on 
both  sides  and  united  over  the  anterior  third  of  the  cleft.  If  this  is 
to  be  done,  the  mucoperiosteal  flap  should  be  freed,  and  the  sutures  in 
this  flap  inserted,  before  the  anterior  parts  of  the  maxillae  are  com- 


C~- 


—  a 


C-- 


Fig.  117.  Approximating  the  maxillae  by  through-aiid-througli  wires.  Anteriorly  is 
shown  how  one  loop  (a')  is  passed  over  the  ends  of  the  second  loop  (b')-  By  drawing 
on  the  (a')  loop,  the  (b')  loop  is  made  to  traverse  both  maxillae,  (b)  shows  loop  in 
position  with  wire;   (C)  ready  to  be  drawn  in  place. 

pletely  approximated.     The  various  steps  of  this  operation  are  illus- 
trated in  Figs.  115  to  119. 

The  needle  shown  in  Fig.  120  is  held  in  a  strong  needle  holder 
and  inserted  high  up  in  the  cul-de-sac,  and  with  a  little  twisting  mo- 
tion it  enters  the  bone  without  difficulty.  As  shown  in  Fig.  121.  in 
young  infants  there  is  no  space  between  the  tooth  and  the  orbit,  and 
the  needle  either  penetrates  the  upper  part  of  the  tooth  sac  or  passes 


186 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


along-  the  upper  surface  of  the  floor  of  the  orbit  (Figs.  121  and  124). 
The  latter  course  is  often  evidenced  by  the  appearance  of  a  subcutane- 
ous orbital  hemorrhage.   We  have  never  seen  any  evil  effect  follow  from 


Pig.    119. 


Fig.    120. 


*  f '^'i,,  •  Approximation  of  the  maxillae  by  through- and-through  wires  Showing 
two  double  wires  in  position  threaded  at  each  end  on  a  lead  plate  (d).  If  single  wires 
are  used,  No.  20  is  the  proper  size,  while  No.  22  or  24  is  used  double. 

*u  ^'S-.,ll'^-  Approximation  of  the  maxillapj  by  through-and-through  wires  This  shows 
the  maxillae  approximated.  This  is  done  by  pressing  the  bones  together  and  talking  up 
the  slack  by  twisting  appropriate  wires.  The  approximation  of  the  alveolar  part  of  the 
cleft  IS  made  more  sure  by  bringing  two  of  the  wires  around  the  intermaxillary  bone 
and  twisting  them  at   (g-g).  a  naij^   uuue. 

Pig.  120.  The  needle  we  use  in  piercing  the  maxillae  is  what  is  known  as  a  %-ciT- 
cle.  reverse-eyed  Hagedorn.  We  use  two  sizes  :  one  of  a  circle  the  size  of  a  nickel  and 
thf  f".       ^  ^  ^'^®  °'  ^  quarter.     Usually  we  grind  off  some  of  the  broad  cut 


CONGENITAL  PALATE  AND  LIP  CLEFTS. 


187 


this.  The  height  at  which  the  needle  may  be  entered  can  be  judged  by 
noting  the  lower  border  of  the  orbit  on  the  face  (Fig.  134). 

Dr.  Brophy  uses  the  needle  illustrated  in  Fig.  125,  and  passes  it 
through  the  gum,  at  a  lower  level  than  described  above.  Though  this 
must  do  some  damage  to  the  developing  deciduous  teeth,  it  cannot  di- 
rectly injure  the  buds  of  the  permanent  teeth,  which  at  this  time  are 
very  small  and  lie  to  the  median  side  of  the  large  crowns  of  the  teeth 
of  the  first  dentition. 

The  wire  we  use  is  a  very  soft  No.  20  virgin-silver  wire.  A  strong 
braided  silk,  or  silkworm  gut,  should  be  used  as  carriers  for  drawing 


c^ 


Ocular  muscles        .^ 
Orbital  fat 

Bony  floor    .    .- 

Molar  tooth  

Buccal  fat 

Upper  gum  .... 


Fig.  121.  Coronal  section  through  frozen  head  of  an  infant  at  term,  through  the 
antrum.  It  will  be  seen  that  there  is  only  a  thin  plate  of  bone  between  the  tooth  sac 
and  the  orbit,  and  that,  in  transfixing  the  maxilla,  the  needle  must  penetrate  one  of  them. 
The  antrum  is  still  very  small  and  lies  mesial  of  the  tooth  sac  of  the  second  molar 
tooth.  By  the  arrow  points  it  will  be  seen  that  the  upper  jaw  is  narrower  than  the 
lower. 

the  wires  through  the  bone.  We  believe  that  placing  the  wires  above 
the  floor  of  the  orbit  and  the  lead  plates  high  up  on  the  alveolar  process 
has  several  substantial  advantages.  The  orbit  is  relatively  large  for 
its  contained  structures,  and  there  is  plenty  of  room  to  pass  the  needle 
above  the  floor  through  the  orbital  fat  without  injuring  the  ocular 
muscles.  The  body  of  the  maxillary  bone  is  rather  compact  and  less 
lacerated  by  the  passage  of  the  needle  and  wires  than  is  the  alveolar 
border.  Where  it  is  desired  to  narrow  the  posterior  part  of  the  cleft, 
the  high  position  of  the  wires  and  plates  gives  a  better  hold  for  reten- 
tion.    It  is  a  surgical  impossibility  to  bring  the  borders  of  the  palate 


188  SURGERY  OF  THE  MOUTH  AND  JAWS. 

processes  in  contact  with  each  other  by  this  operation,  and  even  in 
very  young  infants  the  posterior  part  of  the  cleft  cannot  be  narrowed 
to  anv  considerable  degree  without  employing  a  crushing  force.     This 


Fig.  122.  Coronal  section  tlirougli  plaster  casts  of  the  upper  and  lower  jaws  of  a 
case  of  single  cleft  palate.  By  comparing  the  relative  positions  of  the  arrow  points  in 
this  figure  with  those  in  the  preceding,  it  will  be  seen  that,  while  in  the  normal  state 
the  upper  jaw  is  narrower  than  the  lower,  when  there  is  a  complete  palate  cleft  present 
the  maxillae  are  spread  apart  until  the  upper  jaw  is  wider  than  the  lower.  It  is  for 
this  reason  that  it  is  perfectly  proper  to  approximate  the  maxillae  artificially  in  operat- 
ing   on    a    cleft. 


Fig.  123.  A  study  of  the  growth  of  the  palate  from  infant  to  adolescence.  The 
cross  on  both  palates  is  the  same  size,  18  mm.  in  length  and  20  mm.  in  width,  which 
are  the  full  dimensions  of  the  infantile  palate.  The  measurements  on  the  infantile 
palate  were  taken  from  the  anterior  palatine  canal  to  the  posterior  nasal  spine,  and  be- 
tween the  posterior  palatine  canals.  When  the  cross  of  the  same  dimensions  is  laid  on 
the  adult  palate,  taking  the  anterior  palatine  canal  as  the  fixed  point,  it  will  be  seen  that 
the  cross  piece  is  at  the  level  of  the  posterior  borders  of  the  second  bicuspids,  which  is 
the  original  position  of  the  posterior  palatine  canals,  and  that  while  there  is  a  slight 
lateral  and  forward  growth  of  the  palate,  the  great  part  has  been  backward  ;  which  was 
to  be  expected  because  it  corresponds  to  the  direction  of  growth  of  the  alveoli  of  the 
upper  and  lower  jaws. 

can  be  done  by  covering  the  jaws  of  a  pair  of  long  sequestrum  forceps, 
inserting  them  through  the  mucous  membrane  at  the  upper  fornix  of 
the  vestibule  on  each  side,  and  getting  a  grasp  on  the  bodies  of  the 
maxillary    bones    (Fig.    126),     If    any    pressure    is    exerted    on    the 


CONGENITAL  PALATE  AND  LIP  CLEFTS. 


180 


alveoli,  they  will  fracture  into  the  tooth  sacs,  and  the  teeth  will  be  ex- 
pelled. The  borders  of  the  anterior  part  of  the  cleft  can  be  closed  by 
simply  pressing  open  the  alveoli  with  the  fingers  or  with  the  handle  of 
a  knife,  and  taking  up  the  slack  in  the  wires  by  twisting  them  on  each 
side  alternately.  No  attempt  should  be  made  to  draw  the  bones  to- 
o-ether  by  simply  twisting  the  wires,  and  both  wires  must  share  equally 
in  the  twist,  otherwise  one  of  them  is  apt  to  snap  at  the  plate. 

With  increasing  observation,  we  are  more  and  more  inclined  to  sim- 
ply obliterate  the  anterior  part  of  the  cleft  and  allow  the  posterior  por- 
tion to  take  care  of  itself  until  the  flap  operation  is  performed.     At 


Fig.    125. 


Fig.  124.  An  accurate  diagrammatic  reproduction  of  a  section  of  a  frozen  head  of 
an  infant  with  a  single  cleft  of  the  palate.  This  illustrates  how  a  % -circle  needle  can 
be  made  to  pass  from  the  upper  buccal  fornix,  through  the  jawbone,  along  the  floor  of 
the  orbit  and  into  the  cleft. 

Fig.  125.  Brophy  needle.  Dr.  Brophy  has  two  of  these  made,  right  and  left.  The 
shank  of  this  needle  is  shorter  than  the  original  instrument. 

the  age  of  ten  months  or  two  years,  it  is  usually  easy  to  close  the  pos- 
terior part  of  the  cleft  by  a  von  Langenbeck  operation.  In  the  Brophy 
operation  there  is  little  hemorrhage,  and  unless  too  energetic  efforts 
have  been  made  to  close  the  posterior  part  of  the  cleft,  there  is  no 
shock. 

The  objection  that  has  been  argued  against  this  operation,  that  it 
unduly  narrows  the  palate  and  the  nasal  passages,  is  not  necessarily 
true;  for  the  maxillary  bones  are  already  spread  apart,  and  the  operation 
attempts  simply  to  restore  them  to  the  natural  position.  However,  it 
is  very  easy  in  some  cases  to  carry  the  operation  to  the  extent  of  ob- 
structing the  anterior  part  of  the  nasal  fossa  and  cause  nasal  obstruc- 


190 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


tion  on  one  or  both  sides.  This  point  should  be  carefully  watched,  and 
each  nasal  fossa  should,  in  a  young  infant,  admit  a  probe  with  a  head 
2  or  3  millimeters  in  diameter.  G.  V.  I.  Brown  cites  experiments  car- 
ried on  in  the  Parke-Davis  Laboratories,  which  demonstrated  that  pup- 
pies, in  which  the  nasal  fossa  had  been  obstructed  in  this  manner,  de- 
veloped very  poorly.  We  feel  sure  that  the  infant  has  suffered  in  a 
similar  manner.  The  deciduous  teeth  are  usually  lost  soon  after  the 
operation;  but  this  often  happens  in  cleft  palate  cases  where  no  oper- 
ating has  been  done,  and  is  a  minor  consideration.     In  doing  the  op- 


Pig.    127. 

Fig.  126.  Showing  pcsition  of  the  jaws  of  the  forceps  in  forceful  approximation  of 
the  maxillae. 

Fig.  127.  Double-edged  knife  we.  occasionally  use  in  cutting  the  maxilla.  The 
knife  is  thrust  high  into  the  body  of  the  bone  through  a  small  mucous  opening,  and 
moved  forward  and  backward  In  the  bone. 


eration.  Dr.  Brophy  draws  two  wires  through  each  hole  in  the  bones, 
principally  to  have  a  reserve  in  case  one  wire  breaks.  If  a  soft  No. 
20  wire  is  used,  and  the  wires  are  twisted  only  to  take  up  the  slack 
that  is  gained  by  pushing  the  maxillae  together,  there  will  be  no  danger 
of  their  breaking  short.  The  prominent  intermaxillary  part  of  the 
alveolus  can  be  held  back,  either  by  twisting  two  of  the  long  ends  of 
the  wires  around  the  front  of  the  gum  (Kig.  119),  or  by  passing  a  sep- 
arate finer  wire  through  the  alveolus  on  each  side  of  the  cleft.  If 
the  needle  pierces  the  alveolar  process  of  the  intermaxillary  bone,  it 
should  be  in  the  midline.     By  doing  this,   injury  to  the  buds  of  the 


CONGENITAL  PALATE  AND  LIP  CLEFTS.  191 

permanent  central  incisors  will  be  avoided.  In  either  case  it  is  better 
to  pass  the  wire  through  the  frenum  and  make  the  twist  at  one  side, 
as  this  places  the  wire  higher  on  the  bone.  The  twisted  ends  should 
be  cut  short  and  bent  so  as  not  to  stick  into  the  cheeks. 

The  operation  illustrated  above  is  the  one  we  performed  for  a  num- 
ber of  years  on  every  wide  complete  cleft  in  an  infant  under  three 
months  (Figs.  128  and  129).  Of  late  we  have  been  satisfied,  in 
very  young  infants  with  single  clefts,  to  forcefully  approximate  the 
maxillae  and  pass  one  wire  through  the  anterior  part  of  the  jaws, 
bringing  it  around  in  front  of  the  intermaxillary  bone  without  the  lead 
plates.  This  is  a  simpler  operation,  and  we  believe  here  that  the  results 
are  equally  satisfactory. 


Fig.    128.  Fig.    129.- 

Pig.  128.  Wide  single  cleft  in  a  very  young  infant.  Result  of  the  Brophy  opera- 
tion shown  in  next  figure. 

Fig.  129.  Shows  the  result  that  may  be  obtained  by  the  Brophy  operation,  in  a 
very  young  infant.  In  doing  this,  the  nasal  passages  should  not  be  obstructed.  Although 
this  infant  did  well  in  every  way,  still  drawing  together  the  maxillae  to  the  extent  here 
shown  may  produce  nasal  obstruction. 

The  closure  of  the  posterior  part  of  the  palate  and  velum  is  done 
later  by  the  ordinary  flap-sliding  operation  at  any  time  between  the 
sixth  and  eighteenth  month,  or  even  later.  It  is  easier  to  do  it  at  a 
year  or  eighteen  months  than  at  an  early  period.  It  should  be  done 
before  the  end  of  the  second  year.  The  health  of  the  child,  the  season, 
and  the  state  of  dentition  are  all  to  be  considered. 

It  is  our  custom  to  repair  the  lip  at  the  first  operation  for  the  fol- 
lowing reasons :  Nasal  breathing,  which  is  the  most  important  result 
of  the  operation,  is  thus  established  earlier.  While  these  young  infants 
stand  one  operation  remarkably  well,  they  are  apt  to  do  very  badly  if 
a  second  operation  is  undertaken  within  a  few  weeks  after  the  first. 


192 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Lane,  who  we  believe  does  many  more  early  cleft  operations  than  any 
one  else,  always  closes  the  lip  when  he  closes  the  anterior  part  of  the 
palate,  and  maintains  that  the  healing,  the  cosmetic,  and  the  vital  re- 
sults are  superior. 

LANE  OPERATION. 

In  this  operation  no  attempt  is  made  to  narrow  the  bone  cleft,  but 
the  defect  is  closed  entirely  by  flaps  formed  of  the  soft  tissue.     Advan- 


Pig.   133. 


Pig.  130.  Illusti'ating  what  we  have  for  convenience  designated  as  (a)  and  (c) 
flaps.  In  an  (a)  flap  the  palate  is  incised  at  the  alveolar  border,  and  the  flap  remains 
attached  at  the  cleft  border.  In  a  (c)  flap  the  palate  is  incised  at  the  cleft  border,  and 
the  flap  remains  attached  at  the  alveolar  border. 

Pig.  131.  Diagram  showing  the  Lane  method  of  closing  ,a  single  cleft  of  the  palate. 
An  (a)  flap  is  outlined  on  the  same  side  as  the  cleft  by  the  incision  (d-e-f-g),  and  un- 
dermined as  far  as  the  border  of  the  cleft  in  the  hard  palate.  A  (e)  flap  is  outlined  on 
the  side  opposite  the  cleft  by  the  incision  (a-b-c).  This  is  undermined  to  the  alveolar 
border.  The  (a)  flap  is  swung  under  the  (c)  flap,  as  shown  in  the  next  figure,  and 
broad  raw  surfaces  are  sutured  together.  The  alveolar  part  of  the  cleft  is  filled  with 
tissue  turned  from  the  tip. 

Pig.  132.  Lane's  method  of  closing  a  single  cleft.  This  shows  the  (a)  flap  swung 
into  position  under  the  (c)  flap,  closing  the  anterior  part  of  the  cleft.  At  a  subsequent 
operation  he  makes  the  incision  (g-h)  through  the  mucous  and  submucous  tissue,  and 
loosens  the  posterior  part  of  the  (a)  flap  as  far  as  the  cleft  border  in  the  velum.  At 
the  same  time  another  (a)  flap  is  turned  from  the  upper  surface  of  the  velum  on  the 
opposite  side  as  outlined  by  (c-f-j).  This  second  (a)  flap,  being  turned  from  the  upper 
or  nasal  surface  of  the  velum,  allows  its  raw  surface  to  lie  in  contact  with  that  of  the 
(a)   flap  of  the  opposite  side.     By  this  means  the  cleft  in  the  velum  is  closed. 

Pig.  133.  Lane's  operation.  Illustrating  how  the  (a)  flap  is  turned  from  the 
upper  or  nasal  surface  of  the  velum.     V,  V,  cleft  velum  ;   a,  flap. 


CONGENITAL  PALATE  AND  LIP  CLEFTS. 


193 


tage  is  taken  of  the  fact  that,  there  being  no  teeth  to  interfere,  the  sur- 
geon can  go  past  the  gums  and  on  to  the  cheeks  to  obtain  extensive 
flaps.  These  flaps  are  made  in  several  different  ways.  (See  Chap. 
XII  for  the  general  principles  of  the  making  of  plastic  flaps.)  The 
writer  has  seen  Mr.  Lane  operate  as  follows : 

For  a  through-and-through  single  cleft,  to  close  the  anterior  part, 
he  makes  an  (a)  flap  with  its  base  at  the  cleft  and  a  (c)  flap  (Fig. 
130)  ;  the  (a)  flap  is  rotated  under  the  (c)  flap  and  sutured  (Figs. 
131,  132,  and  133).  This  is  a  modification  of  the  Davies-Colley  opera- 
tion. 

For  a  cleft  behind  the  alveolus,  he  makes  two  (b)  flaps  attached 
posteriorly  with  the  blood  supply  from  the  descending  palatine  arteries. 


Fig.    135. 


Fig.  134.  Lane's  metliod  of  closing  a  cleft  behind  the  incisive  foramen.  The  two 
(b)  flaps  are  outlined  by  (g-f-b-a)  and  (h-e-c-d).  These  are  freed  from  the  alveolar 
and  palate  processes  as  far  back  as  the  descending  palatine  artery.  An  (a)  flap  is  out- 
lined by  (f-b-c-c),  with  its  base  at  the  anterior  end  of  the  cleft.  To  close  the  cleft  in 
the  hard  palate,  the  (a)  flap  is  turned  back  until  its  mucous  surface  is  toward  the  nasal 
fossa,  and  the  two  (b)  flaps  are  drawn  to  the  midline  until  their  raw  surfaces  rest  on 
that  of  the  (a)   flap. 

Fig.  135.  Flaps  in  place,  as  described  under  the  preceding  illustration.  At  a  sub- 
sequent operation  the  cleft  in  the  velum  is  closed,  as  described  under  Fig.  132. 

and  an  (a)  flap  which  includes  the  covering  of  the  anterior  part  of  the 
gum  (Fig.  134).  The  anterior  flap  is  turned  backward  until  it  lies  on 
the  anterior  part  of  the  cleft  with  its  raw  surface  toward  the  mouth; 
and  then  the  two  lateral  (b)  flaps  are  brought  toward  the  median  line, 
their  raw  surfaces  partly  overlying  the  rotated  anterior  flap,  and  all 
are  sutured  in  place  (Fig.  135). 

For  a  wide  double  cleft,  he  makes  an  (a)  flap  on  one  side  and  a 
(b)  flap  on  the  other,  rotating  the  (a)  flap  until  its  raw  surface  is 
toward  the  mouth;  the  (b)  flap  is  drawn  to  the  median  line,  and  they 
are  sutured,  raw  surface  to  raw  surface  (Figs.  136  and  137). 

He  fills  the  anterior  part  of  the  alveolar  cleft  with  flaps  turned  from 
the  edge  of  the  lip  cleft. 


194 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


The  cleft  in  the  vehim  is  repaired  at  a  later  date  hy  two  flaps  made 
as  described  under  Fig.  132. 

When  the  molars  have  erupted,  the  operation  will  differ  but  little 
from  the  Davies-Colley  operation. 

.    Mr.  Lane  uses  fine  silk  and  small  curved  needles,  with  flat  shanks, 
for  fixing  the  flaps. 

It  will  be  seen  from  the  above  description  that,  in  constructing  the 
new  palate,  the  nasal,  as  well  as  the  oral,  surface  is  covered  with  mu- 
cous membrane  and  that  everywhere  broad  denuded  surfaces  are  ap- 
proximated. The  making  of  these  flaps  is  accompanied  by  compara- 
tively little  bleeding.     When  the  posterior  palatine  artery  is  to  be  cut, 


Pig.    136. 

Fig.  136.  Lane  operation  for  complete  double  cleft.  The  operation  is  similar  to 
that  for  single  cleft  except  that  one  side  in  the  latter  (a-b)  flap  is  substituted  for  the 
(c)    flap  used  in  the  former. 

Fig.  137.  Lane's  method  of  closing  a  double  cleft.  Flaps  in  place  for  closure  of 
the  hard  palate  portion  of  a  complete  double  cleft.  As  with  the  single  cleft,  the  alveolar 
part  of  the  cleft  is  closed  with  flaps,  obtained  in  freshening  the  edges  of  the  lip  cleft. 

it  is  first  freed  and  caught  with  an  artery  forceps,  which  is  easily  done, 
as  it  runs  for  a  space  in  a  groove  in  the  palate  process. 

The  above  descriptions  are  less  complete  than  those  given  in  his 
brochure  on  the  subject,  but  they  are  sufficient  to  illustrate  the  princi- 
ples involved. 

The  description  of  the  technique  we  have  given  dififers  from  that 
given  by  Mr.  Lane,  in  the  paper  referred  to,  in  that  the  operations 
here  described  are  performed  in  two  stages.  This  was  the  manner  in 
which  he  was  doing  it  at  a  later  date,  when  we  made  a  special  trip  to 
his  clinic  for  the  purpose  of  getting  his  technique  at  first  hand. 

We  are  convinced  of  the  wisdom  of  the  two-stage  operation,  for, 
in  the  few  cases  we  had  attempted  to  do  the  operation  at  one  sitting, 
we  invariably  had  failure  of  union  in  the  posterior  part  due  to  a  slough- 
ing of  one  flap. 


CONGENITAL  PALATE  AND  LIP  CLEFTS.  195 

CHOICE  OF  OPERATION. 

Granting  that  the  Lane  operation  is  to  be  performed  in  two  stages, 
we  are  sure  that,  at  least  in  ordinary  hands,  when  the  lip  is  repaired  at 
the  same  time  as  the  maxillae  are  approximated,  the  Brophy  operation 
is  superior  for  the  following  reasons :  It  requires  less  technical  skill, 
aims  at  the  restoration  of  a  more  natural  anatomical  condition,  and, 
we  believe,  is  less  of  a  strain  on  the  vital  powers  of  the  patient. 

If,  in  the  Lane  operation,  a  failure  does  occur,  it  is  due  to  slough- 
ing and  a  loss  of  a  part  of  a  flap,  and  the  damage  is  extremely  difficult 
to  repair. 

A  bone  slough  following  a  Brophy  operation  is  very  rare,  but 
when  it  does  occur,  the  damage  is  irreparable. 

AFTER-TREATMENT. 

As  a  general  proposition,  with  the  exception  of  the  special  care  of 
the  mouth,  these  babies  are  to  be  treated  as  if  no  operation  had  been 
done. 

Very  often  after  doing  the  early  operation  on  the  lip,  it  will  be 
found  that  there  is  a  nasal  obstruction  either  from  mucus  in  the  nose 
or,  in  the  case  of  double  harelip,  from  the  temporary  closure  of  the  alae 
of  both  nostrils.  These  babies  will  not,  when  asleep,  breathe  through 
the  mouth,  even  if  the  lower  lip  is  held  to  the  chin  with  a  suture,  as 
has  been  recommended ;  the  tongue  will  fit  up  against  the  new  alveolar 
arch  and  absolutely  preclude  inspiration.  If  this  condition  is  allowed 
to  continue,  they  are  restless  and  do  badly.  We  were  often  greatly 
annoyed  by  this  and  on  two  occasions  went  so  far  as  to  cut  the  sutures 
that  held  the  ala  in  place.  Attempts  to  hold  the  nostril  patent  with  a 
bent  wire  were  unsatisfactory,  because  it  was  not  very  efficient,  and 
also  because  it  caused  the  nostril  to  spread  and  injured  the  cosmetic 
result.  It  was  not  until  we  hit  upon  the  use  of  the  breathing  tube 
(Fig.  206)  that  we  are  able  to  overcome  the  diffifculty.  This  breathing 
tube  is  worn  almost  constantly  for  the  first  few  days,  being  removed 
only  for  feeding.  Usually  after  the  first  two  or  three  days,  it  is  not 
necessary  to  have  it  in  place  constantly,  but  it  is  returned  to  the  mouth, 
whenever  it  is  noticed  that  the  lower  lip  sucks  in  on  inspiration.  After 
five  days,  the  nostrils  usually  open  sufficiently  to  allow  the  tube  to  be 
dispensed  with. 

For  depression  due  to  loss  of  blood,  saline  solution  can  be  given 
hypodermatically.  We  seldom  resorted  to  this,  but  as  a  routine  practice 
have  saline  solution  placed  in  the  rectum. 

At  the  operation  the  child,  almost  invariably,  swallows  blood.  An 
attempt  may  be  made  to  remove  this  with  a  stomach-tube,  but  we  pre- 


196  SURGERY  OF  THE  MOUTH  AND  JAWS. 

fer  to  give  4  cubic  centimeters  of  castor  oil  with  .00  cubic  centimeter 
(gtt.  1)  of  paregoric  within  a  few  hours  after  the  operation.  As  soon 
as  the  infant  cries,  water  is  given,  and  when  this  no  longer  satisfies,  the 
child  of  forty-eight  hours  or  more  is  fed.  Usually  feeding  is  com- 
menced within  four  or  six  hours  after  the  operation.  If  human  milk 
is  available,  it  can  be  given.  After  a  rather  extensive  trial  we  have 
come  to  the  conclusion  that,  for  the  time  being,  most  of  these  babies 
do  better  and  lose  less  weight  if  fed  on  "Eagle  Condensed  Milk"  than 
with  modifications  of  fresh  milk.  After  two  days  the  child  should  be 
encouraged  to  take  the  breast,  if  the  flow  of  milk  has  been  preserved. 
However,  it  will  never  be  able  to  gain  sufficient  nourishment  in  this 
way,  and  the  nursing  should  be  immediately  supplemented  with  milk 
removed  with  a  breast  pump  or  with  condensed  milk  from  a  spoon, 
bottle,  or  dropper.  Older  infants  may  require  an  anodyne  during  the 
first  forty-eight  hours  after  operation.  This  is  rarely  the  case  and 
should  not  be  resorted  to  until  it  is  certain  that  it  is  not  food,  water, 
or  other  ordinary  attention  that  the  child  wants  and  that  a  little  com- 
forting in  the  nurse's  arms  will  not  quiet  it.  Then  and  then  only  may 
a  small  dose  of  paregoric  or  morphin  be  given.  When  avoidable,  such 
a  child  should  not  be  petted  or  handled. 

The  mouth  and  nose  are  gently  irrigated  with  saline  each  two  hours 
during  the  day  and  at  feeding  times  at  night.  The  irrigation  is  done 
with  a  douche  can  and  with  the  child  held  on  its  side  over  a  bucket. 
If  it  does  not  cause  the  child  to  vomit,  the  irrigation  is  made  after  the 
feeding.  If  it  causes  vomiting,  it  is  done  before  feeding.  If  in  older 
babies  the  irrigation  causes  the  child  to  be  afraid  and  to  cry  afterward, 
it  is  omitted.  If  there  is  any  local  evidence  of  infection,  the  part  is 
painted  after  each  irrigation  with  a  10  per  cent  colloidal  silver  solution. 
The  line  of  sutures  on  the  lip  is  painted  with  the  colloidal  silver  as  a 
routine  practice.  Everything  that  is.  used  about  the  child's  mouth  is 
to  be  sterile. 

The  temperature  after  the  operation  may  rise  anywhere  from  99° 
to  103°  F.,  or  even  more,  but  usually  subsides  to  about  100°  and  re- 
mains there  for  a  few  days.  As  a  rule  the  elevation  of  temperature 
needs  no  treatment.  In  good  weather,  older  babies,  those  two  weeks 
old  or  more,  are  taken  out  of  doors  in  a  perambulator  within  a  few 
days  after  the  operation. 

In  dispensary  practice  it  sometimes  takes  nice  judgment  to  deter- 
mine whether  the  danger  of  hospitalism  or  of  improper  care  at  home 
is  more  to  be  feared.  Such  babies  are  usually  kept  at  the  hospital 
ten  days  or  two  weeks,  but  where  the  child  will  receive  intelligent  care 
at  home,  after  the  operation  has  been  done  at  the  hospital,  jt  may  be 
sent  home  within  a  day  or  two. 


CONGENITAL  PALATE  AND  LIP  CLEFTS.  197 

MORTALITY. 

The  immediate  m.ortality  of  the  Brophy  operation  is  very  low.  We 
have  twice  lost  three  months'  children  within  twelve  hours  after  opera- 
tion. We  have  seen  a  few  infants  die  some  weeks  or  months  after 
operation ;  but  this  has  occurred  only  among  cases  in  which  the  nutri- 
tion of  the  infant  was  persistently  bad  beforehand,  and  the  operation 
was  undertaken  in  the  hope  of  improving  the  condition.  In  these  latter 
cases  death  could  not  be  attributed  directly  to  the  operation,  although 
no  doubt  it  had  been  a  contributing  factor.  We  think  it  fair  to  state 
that  we  have  seen  a  much  larger  percentage  of  deaths  among  infants 
that  we  were  trying  to  get  in  shape  for  operation,  than  in  the  first  few 
postoperative  months. 


Fig.   138.      Roberts'  modification  of  Hammoud  palate  clamp. 

Roberts  has  made  a  modification  of  the  Hammond  clamp  for  grad- 
ually approximating  a  bony  cleft.  In  this  clamp  (Fig.  138),  the  teeth 
project  like  hooks  above  the  upper  edge  of  the  jaws.  The  clamp  can 
be  applied  under  anesthesia,  the  mucosa  of  the  upper  fornix  being  first 
incised  to  allow  the  clamp  to  fit  snugly  high  up  on  the  body  of  the  jaw. 
The  clamp  is  tightened  a  little  each  day  or  so,  as  the  segments  of  the 
jaw  come  together.  We  have  never  used  this  clamp,  but  Dr.  Brown 
once  constructed  one  for  us  with  hard  rubber  jaws,  which  were  pressed 
together  with  a  rubber  band.  We  gained  something  by  its  use,  but 
not  much.  The  Hammond-Roberts  instrument  is  much  more  power- 
ful. Roberts  remarks,  "Theoretically  the  method  is  valuable;  but  its 
practical  usefulness  has  not  yet  been  established."  It  seems  to  us  that 
the  two  points  to  consider  in  its  use  are :  how  much  will  its  continued 
use  fret  the  baby,  and  how  much  will  the  instrument  irritate  the  soft 
tissue. 


CHAPTER  XV. 

CONGENITAL  PALATE  CLEFTS— PLASTIC  OPERATIONS 
IN  ORDINARY  CASES  AFTER  EARLY  INFANCY. 

Aside  from  the  general  condition  of  the  patient,  the  first  thing  to 
be  determined  is  the  plan  of  operation  that  is  applicable  to  the  given 
case;  and  the  conclusion  is  to  be  reached  by  a  comparison  of  the 
amount  of  available  tissue  with  the  width  of  the  base  of  the  posterior 
part  of  the  palate  arch.  The  width  of  the  cleft  bears  only  indirectly 
upon  the  question.  The  width  of  the  arch  is  to  be  measured  from 
the  proposed  site  of  one  lateral  incision  to  the  other — from  a  to  a  (Fig. 
139).  The  amount  of  the  palate  tissue  available  is  determined  by  meas- 
uring from  the  site  of  the  lateral  incision  to  the  edge  of  the  cleft  on 
both  sides.  If  in  a  healthy  individual  the  sum  of  the  available  palate 
tissue  is  equal  to  five  sevenths  or  more  of  the  width  of  the  arch  between 


Fig.  139.  Diagram  of  a  section  through  a  cleft  palate.  The  distance  between 
a  and  a'  is  the  width  of  the  palate ;  a  and  a'  mark  the  sites  of  the  lateral  Incisions. 
The  distances  between  a  and  &  and  between  a'  and  b'  give  the  amount  of  available  palate 
tissue. 

the  two  lateral  incisors,  the  case  is  a  proper  one  for  the  simple  von 
Langenbeck  operation.  That  is,  if  the  direct  distance  from  one  lateral 
incision  to  the  other  is,  for  example,  35  millimeters  and  the  sum  of  the 
widths  of  the  available  tissue  for  flaps  is  25  millimeters,  then  the  pro- 
portion is  25  millimeters  of  palate  tissue  to  35  millimeters  of  palate 
width.  Here  the  10  millimeters  of  missing  palate  tissue,  plus  the  5 
millimeters  that  will  be  lost  by  paring  the  edges,  will  be  compensated 
for  by  the  spreading  at  the  site  of  the  lateral  incisions.  If  the  propor- 
tion of  tissue  is  smaller,  the  chances  of  success  will  be  greatly  in- 
creased, if  it  be  treated  by  one  of  the  operations  given  under  "Difficult 
Cases,"  Cha]).  XVI.  We  have  seen  a  few  cases  that  were  difficult  to 
close  when  the  proportion  of  palate  tissue  to  palate  width  was  greater 
than  5  to  7. 

198 


CONGENITAL  PALATE  CLEFTS.  199 

PREPARATION  FOR  OPERATION. 

Before  the  operation  is  undertaken,  it  should  be  determined  whether 
the  patient  is  in  a  good  physical  condition,  is  at  the  time  free  from  a 
cough  or  "cold,"  is  not  cutting  teeth,  and  is  not  likely  to  break  out 
with  some  eruption  or  contagious  disease.  Children  that  are  known  to 
have  been  exposed  to  one  of  the  last  should  not  be  subjected  to  the 
operation  until  after  the  time  of  incubation  has  passed.  The  subjects 
of  active  syphilis  should,  for  the  time  being,  be  excluded  from  opera- 
tion. Phthisical  persons  should  not  be  subjected  to  the  depressing 
effects  of  any  surgical  procedure,  unless  there  is  some  special  indication 
for  doing  so.  In  one  of  the  latter,  a  middle-aged  woman,  we  repaired 
the  palate,  for  the  reason  that,  having  no  upper  teeth  and  on  account 
of  the  cleft,  she  was  not  able  to  wear  a  plate,  and  her  depressed  physi- 
cal condition  was  partly  due  to  faulty  nutrition. 

If  there  are  decayed  teeth  in  the  mouth,  they  should  usually  be 
treated  or  removed,  and  if  the  teeth  are  not  free  from  tartar,  they  should 
be  cleaned  by  a  dentist  before  the  operation.  If  there  is  any  persistent 
source  of  pus  in  the  mouth,  it  should  be  treated,  if  necessary,  by  ap- 
propriate vaccines.  This  refers  also  to  suppuration  of  the  accessory 
sinuses  of  the  nose. 

Having  eliminated  all  acute  diseases  and  all  evident  possible  sources 
of  irritation  and  infection,  the  mouth  of  the  older  child  or  adult  may 
be  rinsed  frequently  for  twenty-four  hours  before  the  operation  with 
a  mild  antiseptic  wash.  Food  and  water  should  be  withheld  for  a  suf- 
ficient time  before  the  operation  to  be  certain  that  the  stomach  will  be 
empty,  and  if  indicated — not  as  a  routine  practice — a  laxative  may  be 
given.  It  is  our  practice  to  give  water  in  reasonable  amounts  up  to 
an  hour  before,  and  some  form  of  liquid  food  exclusive  of  fresh  milk 
about  four  hours  before  the  operation. 

POSITION  AND  LIGHT. 

During  the  operation  the  patient  may  be  sitting  erect,  lying  flat  on 
the  back,  lying  on  one  side,  or  lying  on  the  back  with  the  head  hanging 
over  the  end  of  the  table.  The  latter  is  known  as  the  Rose  position, 
and  this,  or  the  lateral  position,  is  the  one  we  prefer.  Both  of  these' 
positions  have  one  great  advantage :  the  blood  drains  away  from  the 
larynx.  The  Rose  position  may  be  modified  to  this  extent :  the  head 
rests  on  a  pillow  on  the  surgeon's  knees  or  in  the  hands  of  an  assistant, 
which  lessens  the  strain  on  the  unconscious  patient's  neck.  To  support 
the  head  on  the  lap  comfortably,  there  must  be  a  proportion  between 
the  stature  of  the  operator,  the  height  of  the  operator's  stool,  and  the 
height  of  the  table.  It  is  well  to  have  arranged  this  detail  before  the 
operation  is  undertaken.     The  pad  upon  which  the  patient  lies  should 


200  SURGERY  OF  THE  MOUTH  AND  JAWS. 

extend  beyond  the  table  so  that  the  neck  will  be  protected.  This  pad 
may,  very  satisfactorily,  be  made  of  folded  blankets  covered  with  rub- 
ber, A  pillow  placed  under  the  shoulders  is  unsatisfactory  as  it  does 
not  stay  in  place.  With  the  patient  in  the  lateral  or  in  the  Rose  posi- 
tion, the  instrument  table  is  to  be  placed  to  the  right  of  a  right-handed 
operator.  The  anesthetist  stands  behind  or  to  the  patient's  left,  and 
the  assistant  to  the  right,  both  facing  the  surgeon.  If  the  head  is  to 
be  supported  in  the  hands  of  a  second  assistant,  he  sits  to  the  left  be- 
tween the  surgeon  and  the  anesthetist.  The  light  should  be  good — 
daylight  from  a  side  window.  This  is  preferable  to  artificial  light,  but 
as  a  rule  in  cities,  in  winter,  electricity  is  more  dependable.  If  the  light 
is  from  a  cluster,  the  patient  should  be  placed  in  such  a  relation  to  it 
that  the  light  will  fall  directly  into  the  mouth.  Unless  the  operator 
is  very  accustomed  to  its  use,  a  head  mirror  is  not  satisfactory,  as  it 
destroys  the  sense  of  perspective,  but  an  electric  headlight  is  not  open 


Fig.  140.      Lane  gag. 

to  this  objection.     A  hand  light  is  not  as  good  for  this  purpose.     It  is 
absolutely  essential  to  good  work  that  the  light  be  excellent, 

INSTRUMENTS  AND  MATERIALS. 

Next  in  importance  to  the  light  is  the  mouth  gag.  The  profusion 
of  varieties  presented  in  any  instrument  catalogue  should  by  their  num- 
ber suggest  caution  to  the  surgeon  in  selecting  one.  Rather  than  waste 
time  with  a  poorly  adapted  gag,  it  is  better  to  place  a  block  of  wood 
or  cork  between  the  molars  on  one  side  and  then  firmly  wire  a  tooth 
in  the  lower  jaw  to  a  tooth  in  the  upper  jaw,  just  in  front  of  the  block. 
Roughly,  gags  may  be  divided  into  two  classes :  those  that  are  de- 
signed solely  for  the  purpose  of  separating  the  jaws,  and  others  that, 
besides  holding  open  the  mouth,  are  supposed  to  depress  the  tongue. 
Of  the  former  variety  there  are  two  general  types :  the  kind  which 
rests  on  the  incisor  teeth,  and  those  which  are  inserted  between  the 
molars.     As  a  rule  the  former  is  more  satisfactory  where  it  can  be 


CONGENITAL  PALATE  CLEFTS. 


201 


used,  but  it  is  hardly  applicable  to  clefts  that  involve  the  alveolar 
process.  If  a  posterior  gag  is  used,  the  Lane  type  (Fig.  140)  is  prefer- 
able to  the  ordinary  kind.  Whatever  kind  is  selected,  see  that  it  is 
strong  enough  and  has  a  reasonable  inclination  to  stay  in  place.  Of 
the  gags  that  are  intended  to  depress  the  tongue,  we  are  familiar  v^ith 
three  varieties  that  are  useful  if  the  size  and  shape  of  the  particular 
model  at  hand  corresponds  to  the  patient's  mouth.  One  is  the  White- 
head gag  (Fig.  165),  which  comes  in  two  sizes,  but  which,  taking  its 
bearing  at  the  incisor  teeth,  is  not  suitable  to  cases  of  through-and- 
through  cleft.  The  same  holds  true  of  the  Murdock  gag,  which  has 
lately  appeared  with  a  tongue  depressor  attached.  Mr.  Owen's  modifi- 
cation of  the  Smith  gag,  which  is  made  by  Weiss  of  London,  and  comes 


Fig.  141.     Owen's  iiiodiflcation  of  Smith  gag. 

in  three  sizes,  is  shown  in  Fig.  111.  The  spiked  rests  are  applied  to  the 
gums  behind  the  molars,  and  if  the  gag  fits  properly,  they  will  not  slip. 
The  simplest  of  all  is  Dr.  Brophy's  oral  speculum.  While  its  very  sim- 
plicity recommends  it,  it  does  not  give  as  much  working  room  as  do 
the  other  two,  and  to  assure  having  one  to  exactly  fit  a  given  case,  it  is 
necessary  that  quite  a  variety  of  sizes  and  shapes  be  at  hand. 

Having  provided  for  a  satisfactory  light  and  gag,  the  rest  of  the 
necessary  armamentarium  is  rather  simple,  and  should  consist  of  a 
small  pointed  knife  that  is  sharp  enough  to  cut  a  suspended  hair  as 
freely  as  a  razor.  This  knife  must  be  resharpened  for  each  operation. 
It  is  very  rare  that  a  new  knife,  as  it  comes  from  the  dealer,  is  sharp 
enough  to  be  perfectly  satisfactory.  It  saves  the  edge  of  the  sharp 
knife  to  have  a  second  for  making  the  lateral  incisions. 


202 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


There  should  be  at  least  one  dozen  artery  forceps  for  sponging  and 
clamping  ligatures  to  the  head  cloth.  One  or  two  of  the  forceps  should 
be  pointed. 

For  a  needle  holder  we  use  an  ordinary  Halsted  artery  forceps,  but 
with  it  use  a  needle  that  has  a  flat  shank.  An  artery  forceps  will  hold 
a  flat-shanked  needle  a  little  obliquely,  which  is  an  advantage.  The 
artery  forceps  will  not  prevent  a  round  needle  from  turning.  One  pair 
of  plain  dissecting  forceps  is  needed  for  manipulating  the  needles,  and 
a  pair  with  long  mouse  teeth  is  useful  for  catching  small  pieces  of  tissue 
that  are  to  be  removed.     There  is  a  forceps  that  combines  these  two 


LU 


a 


Lr 


B 


Fig.  142.  An  easily  constructed  tenaculum  for  handling  palate  flaps.  The  one 
shown  above  (A)  is  made  to  both  push  and  to  pull  on  the  flaps,  but  this  double-ended 
needle  is  liable  to  catch  in  the  tissues.  We  prefer  to  use  two,  one  to  push  and  the  other 
to  pull  (C  and  D).  They  are  made  by  filing  a  groove  in  the  end  of  the  blade  of  a 
Halsted  forceps   (B)   and  setting  in  the  point  of  a  fine  cambric  needle. 

features.  The  flaps  themselves  should  never  be  grasped  with  any  kind 
of  pressure  forceps.  Several  varieties  of  hooks  and  tenacula  have 
been  devised  for  this  purpose,  but  the  scheme  shown  in  Fig.  142  can  be 
prepared  by  anyone  and  is  extremely  satisfactory. 

For  cutting  the  palate  aponeurosis  and  nasal  mucous  membrane 
from  the  posterior  border  of  the  hard  palate,  the  straight  knife  is  ef- 
ficient only  when  the  cleft  extends  well  forward  into  the  bony  palate. 
Nevertheless,  in  all  cases,  a  pair  of  thin-bladed  sharply  curved  scissors 
are  more  satisfactory.  The  curved  knives  made  for  this  purpose  are 
difficult  to  sharpen,  and  the  angle  knives  tend  to  split  the  velum  longitu- 
dinally. The  scissors  shown  in  Fig.  143  are  tonsil  scissors,  one  pair  of 
which  were  especially  ground  for  infants'  mouths.     Any  pair  of  small 


CONGENITAL  PALATE  CLEFTS. 


203 


scissors  that  ape  curved  on  the  flat  or  side  will  do,  provided  the  curve 
is  sufficiently  sharp. 

Unless  the  tongue-depressing  device  on  the  gag  is  absolutely  satis- 
factory, a  narrow-curved  spatula  is  required  for  controlling  the  tongue. 

The  kind  of  elevator  used  will  depend  somewhat  upon  whether  the 
operator  chooses  to  begin  freeing  the  mucoperiosteal  flap  from  the  cleft 
border  or  from  lateral  incisions  made  at  the  outer  border  of  the  palate. 
For  the  latter  procedure,  the  most  satisfactory  are  those  devised  by 
Dr.  Brophy  (Fig.  144).  The  acute  angle  of  the  second  one  is  very 
useful  in  freeing  the  anterior  part  of  the  flap  in  a  highly  vaulted  arch. 
Freeing  the  flap  from  a  lateral  incision  is  the  more  rational  and  satis- 


I 


Fig.   143.      Tonsil  scissors  that  may  be  used  for  cutting  the  palate  aponeurosis, 
smaller  pair  have  been  ground  for  an  infant's  mouth. 


The 


factory  procedure,  and  a  very  good  instrument  for  this  purpose  is  the 
one  devised  by  Dr.  Willard  Bartlett  (Fig.  145).  With  ordinary  care  it 
will  not  cut  the  descending  palatine  artery  and  will'  work  both  an- 
teriorly and  posteriorly  through  a  small  incision   (Fig.  146). 

It  will  be  noted  that  all  of  the  instruments  mentioned  are  unpaired 
and  can  be  used  at  either  side  of  the  palate. 

Sutures. — In  the  selection  of  suture  material,  we  have  traveled 
somewhat  in  a  circle.  It  is  well  recognized  that  silver  wire  is  tolerated 
better  in  tissues  exposed  to  sepsis  than  any  other  suture  material. 
However,  the  ordinary  way  of  inserting  it  with  silk  carriers  is  cumber- 
some and  time  consuming,  and  it  is  not  always  convenient  to  be  de- 
pendent upon   a   special   instrument,   such  as   the   OAven  needle.     We 


204 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


used  horsehair  for  some  time,  but  abandoned  it  on  account  of  the 
fear  of  tetanus.  Its  elasticity,  the  ease  with  which  it  is  handled,  and  its 
non-irritating  character  all  unite  to  make  horsehair  an  excellent  suture. 
Later  we  used  a  fine  silkworm  gut,  but  noticed  that  not  infrequently 
sepsis  apparently  had  its  origin  at  a  suture  hole.  We  are  now  using 
a  No.  30  soft-silver  wire,  threaded  directly  on  a  Ferguson  needle. 
With  a  little  care  it  can  be  made  to  follow  the  needle  without  tearing 
the  tissues,  and  in  using  it  in  this  way,  we  believe  we  have  overcome 
the  only  objection  to  its  use.  To  use  silk  and  linen  seems  objectionable 
because  by  their  capillarity  they  promote  sepsis.     There  is  little  unan- 


Fig.   144.      Brophy  palate  elevators. 


Fig.   145.      Bartlett  elevator. 


imity  of  opinion  about  palate  suture  material.  Among  the  operators 
of  large  experience:  Lane  uses  silk,  Judd,  of  Rochester,  uses  linen, 
Brophy  uses  horsehair,  while  Gilmer  and  Owen  both  use  silver  wire. 
In  using  silver  wire,  the  sutures  are  at  first  twisted  but  loosely,  or  held 
to  one  side  with  forceps.  After  all  are  in  place,  they  are  twisted  to  the 
proper  tension. 

In  most  instances  we  use  a  small  Ferguson  needle  which  has  a  flat 
shank.  The  needle  shown  in  Fig.  147  is  extremely  useful  and  some- 
times almost  indispensable  in  repairing  a  partial  union  after  a  primary 
operation,  when  the  defect  is  situated  in  the  hard  palate  and  the  edges 
of  the  flaps  are  thick  and  inverted  in  the  nasal  fossa  (Figs.  148  to  151). 
The  variety  of  right  and  left-curved  needles  on  handles  that  are  offered 


CONGENITAL  PALATE  CLEFTS. 


205 


by  instrument  makers  for  palate  suturing  are  absolutely  unnecessary, 
and  many  of  them,  on  account  of  their  bad  lines,  are  impossible. 

If  retention  sutures  and  lateral  plates  are  to  be  used,  small  pierced 
shot  are  the  most  convenient  means  of  fixing  the  retention  sutures  in 
the  lead  plates.  The  lead  from  which  the  plates  are  cut  is  about  1 
millimeter  thick.  The  lead  plate  can  be  obtained  from  a  plumber  and 
rolled  or  beaten  out  to  the  desired  thickness.  The  shot  can  be  bought 
from  an  instrument  dealer,  or  ordinary  shot  can  be  drilled  out  by  hand. 

Sponges.— Though  very  satisfactory,  marine  sponges  are  no 
longer  popular.  For  sponging  ofif  the  flaps,  small  wads  of  absorbent 
cotton,  that  have  been  wet  and  wrung  out  very  thoroughly  by  squeez- 
ing, are  very  satisfactory.  For  removing  the  blood  from  the  naso- 
pharynx, loosely  folded  squares  of  dry  gauze,  5  centimeters  wide,  and 
four  thicknesses  of  gauze,  are  better  adapted.  .  Unless  the  sponges  are 


Fig.   146.      .Method  of  use  of  Bartlett  elevator. 

rewashed  during  the  operation,  there  should  be  a  large  supply  to  pro- 
vide for  excessive  bleeding  and  emergencies.  We  find  it  convenient  to 
have  on  hand  some  folded  strips  of  gauze  to  temporarily  pack  the 
lateral  incisions,  when  bleeding  is  free.  These  are  to  be  removed  be- 
fore inserting  the  sutures. 

The  instruments,  sponges,  and  sutures  should  be  laid  out  in  an  or- 
derly way  on  a  table  to  the  right  of  a  right-handed  operator  and  should 
be  well  within  his  reach  and  view. 


FLAP-SLIDING  OPERATION. 

The  patient,  being  anesthetized,  is  placed  in  the  desired  position,  and 
the  hair  is  covered  with  a  rubber  cap ;  over  this  is  placed  a  sterile  pro- 
tective cloth  that  covers  the  nape  of  the  neck  behind  and  the  eyes  in 
front,  enveloping  the  whole  head.  This  is  put  on  firmly  so  that  it  will 
not  slip  and  is  pinned,  or  is  clamped  with  artery  forceps.     Whether  or 


206 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


not  there  is  a  tongue  depressor  on  the  gag,  a  traction  suture  is  passed 
through  the  tongue,  the  two  ends  being  knotted  together  so  that  it 
will  not  slip  out.  This  suture  should  transfix  the  tongue  at  least  1.5 
centimeters  from  the  tip  and  be  of  soft  silk  that  will  not  cut  through. 
Being  satisfied  with  the  view  that  can  be  obtained  of  the  palate,  in- 
cluding the  uvula,  and  that   the  tongue   depressor  is   not   interfering 


Fig.    147. 


Pig.    149. 

Fig.    147.      Shepherd's  crook  needle. 

Fig.  148.  The  palate  flap  may  be  steadied  with  a  prod  while  the  shepherd's  crook 
needle  is  inserted. 

Fig.  149.  McCurdy'm  method  of  using  shepherd's  crook  needle.  First  step  :  The 
threaded  needle  is  passed  through  the  cleft,  and  the  palate  flap  is  transfixed  from  its 
upper  surface.  Second  step:  The  loop  (a-a)  is  caught,  and  the  suture  end  (a)  of  (a-a) 
is  withdrawn  through  the  palate,  so  that  it  hangs  in  the  mouth  but  is  not  withdrawn 
from  the  eye  of  the  needle. 


with  respiration,  the  mucus  is  sponged  from  the  nasopharynx,  and  the 
operation  proceeds  somewhat  as  follows : 

A  lateral  incision  is  made  on  either  side  opposite  the  position  of  the 
last  molar  tooth.  If  the  patient  is  lying  on  the  side,  the  lateral  in- 
cision is  made  on  the  side  of  the  palate  that  is  next  to  the  table.     If 


CONGENITAL  PALATE  CLEFTS. 


207 


the  molar  tooth  has  erupted,  the  incision  is  made  4  milHmeters  from 
the  gingival  border.  If  the  tooth  has  not  erupted,  the  incision  is  car- 
ried along  the  line  of  junction  of  the  palate  surface  with  the  most 
prominent  part  of  the  gums.  The  incision  is  made  just  median  of  the 
last  two  molar  teeth,  extends  directly  to  the  bone,  and  is  made  as  close 
as  possible  to,  without  absolutely  denuding,  the  necks  of  the  teeth. 
Behind  the  last  molar  tooth  the  incision  is  carried  along  the  crest  of  the 
alveolar  process.  As  Mr.  Owen  tersely  puts  it:  "The  closer  these 
incisions  are  made  to  the  teeth,  the  less  chance  of  wounding  the  de- 


Fig    151. 


Fig.    150. 


Fig.    152. 


Fig.  150.  McCurdy's  method  of  using  sliepherd's  crook  needle.  Third  step  :  The 
needle  still  threaded  is  withdrawn  from  the  first  flap,  turned  180  degrees  in  the  axis  of 
its  handle,  and  inserted  into  the  second  flap  from  its  upper  surface.  Fourth  step :  The 
loop  (b-b)  is  caught,  and  the  suture  end  (b)  of  (b-b)  is  withdrawn  from  the  eye  of  the 
needle.     Fifth  step :  The  unthreaded  needle  is  removed. 

Fig.  151.  After  placing  a  suture  with  the  shepherd's  crook  needle,  it  can  be  con- 
verted into  a  vertical  mattress  suture  by  the  use  of  a  small  needle. 

Fig.  152.  The  blades  (S,  S)  of  a  pair  of  eurved-ou-the-flat  scissors  In  position 
to  cut  the  palate  aponeurosis  and  nasal  mucous  membrane  from  the  posterior  border  of 
the  bony  palate;  (mp)  is  the  mucoperiosteum  separated  from  the  bony  palate;  (p)  is 
the  bony  palate ;  (v)  is  the  velum. 

scending  palatine  arteries,  the  broader  will  be  the  flaps,  and  the  less 
likelihood  of  their  blood  supply  being  seriously  interfered  with." 

In  the  original  von  Langenbeck  operation,  which  with  us  is  the 
method  of  choice,  the  elevator  that  dissects  the  palate  flaps  is  inserted 
through  the  lateral  incision.  In  raising  the  flap,  the  point  of  the  ele- 
vator, which  should  not  be  sharp,  is  kept  close  to  the  bone  so  that  the 
artery  and  nerves  will  be  lifted  with  the  flap.  Just  in  front  of  the 
opening  of  the  posterior  palatine  canal  they  lie  in  a  distinct  bony 
groove.  While  these  are  to  be  lifted  from  the  groove,  the  point  of  the 
elevator  should  not  dig  into  the  opening  of  the  canal.     The  vessels  will 


208  SURGERY  OF  THE  MOUTH  AND  JAWS. 

stretch,  and  the  nerves  yield  until  the  flap  can  be  moved  toward  the 
median  line  for  an  astonishing  distance.  It  is  usually  practical  to  break 
through  into  the  cleft  with  the  elevator  at  the  junction  of  the  nasal  and 
palate  mucous  membranes,  thus  doing  away  with  the  necessity  of 
paring  the  borders  of  the  cleft  in  the  hard  palate.  If  it  is  considered 
desirable  to  pare  the  borders  of  the  cleft  in  the  hard  palate,  it  is  done 
as  follows: 

In  the  case  of  a  double  cleft,  a  strip  of  tissue  may  be  removed  down 
to  the  bone,  from  the  mucoperiosteal  edge,  on  both  sides,  by  reversing 
the  position  of  the  knife  and  cutting  anteriorly  as  far  as  the  limit  of 
the  cleft  (Figs.  153  and  154). 

In  a  single  cleft,  part  of  the  mucous  covering  of  the  nasal  septum 
may  be  utilized  with  the  palate  flap  on  the  side  to  which  the  nasal 
septum  is  attached.  An  incision  is  carried  through  the  mucous  cov- 
ering along  the  surface  of  the  septum  parallel  with  the  palate  (Fig. 
110).  The  height  above  the  palate,  at  which  this  incision  is  made,  will 
depend  upon  the  amount  of  flap  that  is  needed.  If  this  incision  on 
the  septum  is  to  be  made  at  a  considerable  height  above  the  palate, 
unless  one  has  an  especially  constructed  knife,  it  is  best  made  by  pass- 
ing a  small  tenotome  through  the  opening  of  the  nostril  on  the  cleft 
side  and  incising  the  mucous  covering  of  the  septum  from  behind  for- 
ward, and  then  connecting  the  anterior  and  posterior  ends  of  this  in- 
cision with  those  at  the  palate  border. 

In  clefts  that  extend  well  forward  into  the  hard  palate,  it  is  often 
convenient  to  free  the  extreme  anterior  part  of  each  flap  by  working 
from  the  cleft  border.  For  this  purpose,  the  Brophy  elevator,  that  has 
the  blade  bent  at  an  acute  angle  (Fig.  144),  is  especially  useful. 

The  mucoperiosteal  flap  having  been  dissected  from  the  surface  of 
the  bone  on  one  side,  the  next  and  absolutely  essential  step  is  to  free 
the  velum  from  the  hard  palate  by  cutting  the  palate  aponeurosis  and 
the  nasal  mucous  membrane  at  the  posterior  border  of  the  palate  pro- 
cess. This  may  be  accomplished  in  clefts  that  involve  both  the  hard 
and  soft  palates  by  passing  a  knife  between  the  palate  process  and  the 
mucoperiosteal  flap  and  cutting  upward  and  backward.  In  all  cases, 
however,  it  is  more  conveniently  done  by  passing  one  blade  of  a  pair 
of  sharply  curved  scissors  between  the  bone  and  the  flap  and  the  other 
blade  into  the  nasopharynx  (Fig.  152).  The  mucoaponeurotic  layer 
should  be  severed  from  the  hard  palate  as  far  as  the  lateral  incision. 
When  the  velum  is  freed,  it  should  be  possible  to  carry  the  median  edge 
of  the  half  palate  well  past  the  median  line  without  tension.  If  it  is 
not  sufficiently  movable,  the  fault  will  probably  be  that  the  aponeurosis 
has  not  been  entirely  severed.  If  the  tension  is  due  to  contraction  of 
the  tensor  palati  muscles,  it  can  be  relieved  by  Billroth's  plan  of  in- 


CONGENITAL  PALATE  CLEFTS. 


209 


serting  a  small  chisel  guided  by  the  finger  into  the  lateral  incision,  and 
fracturing  the  hamular  process  at  its  base.  This  will  not  permanently 
cripple  the  action  of  the  muscle.     The  lateral  incision  is  not  to  be  ex- 


Fig.   153. 


Fig.    154. 


Fig.  153.  Prod  and  knife  in  position  for  denuding  the  left  cleft  border,  in  ele- 
vating the  mucoperiosteal  flaps  from  the  hard  palate,  they  are  at  the  same  time  freed 
from  their  continuity  with  the  nasal  mucosa.  Therefore  it  is  unnecessary  to  extend 
the  cuts  anterior  of  the  junction  of  the  velum  with  the  hard  palate. 

Fig.  154.  Knife  and  prod  in  position  for  paring  the  right  cleft  border.  Ribbon  of 
tissue  is  shown  hanging  from  the  left  border  of  the  cleft.  If  the  border  of  the  cleft  in 
the  hard  palate  has  been  freed  with  the  elevator,  the  paring  is  done  only  in  the  velum. 


tended  straight  backward  indefinitely.  At  a  point  1  centimeter  behind 
the  hamular  process  the  ascending  palatine  arteries  may  be  cut,  and 
with  them  possibly  the  nerve  supply  of  the  levator  palati  muscles.     If 


210  SURGERY  OF  THE  MOUTH  AND  JAWS. 

further  freeing  is  necessary,  it  is  better  to  carry  the  incision  backward 
and  outward  to  the  outer  side  of  the  anterior  border  of  the  ramus  of 
the  mandible.  This  may  later  cause  some  stiffness  in  opening  the 
mouth,  but  this  can  be  later  overcome  by  a  soft  rubber  dilator.  If  par- 
tial failure  occurs  after  operation,  it  is  usually  at  the  junction  of  the 
hard  palate  and  velum,  and  therefore,  the  flaps  should  be  sufficiently 
free  in  this  part.  The  distance  to  which  the  lateral  incision  may  be 
carried  anteriorly  will  depend  upon  whether  the  trunk  of  the  descend- 
ing artery  has  been  injured  in  loosening  the  flap.  If  the  artery  has  not 
been  cut,  the  incision  may  be  prolonged  forward  any  distance  without 
endangering  the  blood  supply,  but  unless  it  is  certain  that  the  vessel 
is  intact,  the  incision  should  not  be  extended  in  this  direction.  If  for 
lack  of  this  incision  it  is  found  impossible  to  coapt  the  edges  of  the 
flap  in  front,  it  is  better  to  unite  the  posterior  part,  and  postpone  the 
anterior  part  to  a  later  operation,  than  risk  the  misfortune  of  a  slough- 
ing of  this  part  of  the  flap.  The  freeing  of  the  flaps  should  be  com- 
pleted at  this  time.  To  extend  the  lateral  incisions  after  completing 
the  suturing  is  to  court  hemorrhage  that  may  require  repacking.  Hav- 
ing ascertained  that  the  palate  flap  is  sufficiently  freed,  bleeding  is  con- 
trolled by  temporarily  packing  the  lateral  incision  with  a  strip  of  gauze. 
The  freeing  of  the  flap  having  been  completed  on  one  side,  and  hemor- 
rhage controlled,  it  is  repeated  on  the  other.  When  methodically  and 
properly  done,  this  part  of  the  operation  takes  but  a  few  minutes. 
Whether  the  performing  of  the  whole  operation  will  require  thirty-five 
minutes,  or  an  hour  or  more,  will  usually  depend  entirely  upon  the 
care  which  has  been  given  to  each  detail  at  the  proper  time.  Very  oc- 
casionally anesthetic  difficulties  or  hemorrhage  will  be  an  unavoidable 
cause  of  delay.  There  are  a  few  operators  of  considerable  experience 
who  free  the  flaps  by  inserting  the  elevator  from  the  cleft  border,  with- 
out making  lateral  incisions,  but  this  is  not  the  practice  of  the  majority. 

During  the  whole  course  of  the  operation,  bleeding  is  to  be  con- 
trolled mostly  by  temporary  pressure ;  occasionally  an  artery  can  be 
caught  with  toothed  forceps,  but  rarely  can  a  ligature  be  applied. 
Sometimes  a  bleeding  vessel  can  be  included  in  a  suture,  but  this  pro- 
cedure is  not  to  be  recommended  where  there  is  any  danger  of  limiting 
the  blood  supply  of  the  flap.  Although  several  writers  have  stated  that 
it  is  of  little  consequence,  the  cutting  of  the  descending  palatine  arter- 
ies is  to  be  dreaded  more  on  account  of  the  danger  of  ischemia  than 
from  hemorrhage,  which  is  usually  controlled  by  temporary  pressure 
or  packing  under  the  flap.  Plugging  the  canal  has  been  recommended 
to  control  bleeding  from  this  artery,  but  we  have  never  found  it  neces- 
sary. 

During  the  operation,   the  nasopharynx   is  to  be  kept   free   from 


CONGENITAL  PALATE  CLEFTS. 


211 


blood.   If  one  can  satisfy  himself  that  he  can  sterilize  marine  sponges, 
they  are  more  efficient  than  any  of  the  newer  substitutes. 

The  flaps  having  been  properly  loosened  on  both  sides,  the  next 
step  is  paring  the  borders  of  the  cleft  in  the  velum.  The  prod  (Fig. 
143)  is  held  in  the  left  hand,  and  is  inserted  into  the  uvula  near  its  tip, 
taking  a  good  hold  (Fig.  153).  By  pushing  downward  and  backward, 
the  cleft  edge  of  the  velum  is  made  tense.  The  point  of  the  knife,  with 
its  cutting  edge  toward  the  uvula,  transfixes  the  velum  at  its  base  about 
2  millimeters  from  the  cleft  edge  and  cuts  a  ribbon  of  tissue  from  the 


Pig.    155. 


Fig.    156. 


Fig.  155.  Shows  first  insertion  of  the  needle  at  the  junction  of  the  hard  and  soft 
palatBr 

Fig.  156.  Showing  the  last  insertion  of  the  needle  for  the  superficial  part  of  the 
vertical  mattress  suture.  This  suture  has  the  advantage  of  approximating  broad  ravr 
surfaces. 


free  border,  as  far  as  the  base  of  the  uvula,  that  leaves  a  raw  surface 
5  to  8  millimeters  wide.  The  median  border  of  the  cleft  velum  is  one 
edge  of  a  prism,  and  a  slight  variation  of  the  angle  at  which  the  knife 
is  held  will  make  a  considerable  difference  in  the  width  of  the  result- 
ing raw  surface.  We  have  for  some  time  ceased  to  pare  and  unite 
the  two  halves  of  the  uvula,  for  the  reason  that,  when  this  is  done,  the 
latter  shrinks  to  a  small  nodule,  while  the  two  halves  of  the  uvula,  if 
not  molested,  help  to  fill  in  the  space  to  an  appreciable  extent. 

We  advocate  postponing  the  denuding  of  the  cleft  border  until 
after  the  flaps  are  freed  from  the  bone,  for  the  reason  that,  by  doing 


212 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


so,  the  raw  surfaces  are  exposed  for  a  shorter  time  before  being  coapted 
by  sutures.  In  actual  practice  it  will  be  found  that,  after  the  palate 
flaps  and  velum  have  been  freed  from  the  bone,  they  become  much 
elongated,  and  it  is  now  difficult  to  hold  them  tense  while  the  denuda- 
tion is  made.  It  is  of  the  utmost  importance  that  the  sutures  be  not 
drawn  too  tight.     This  is  apt  to  cause  sloughing  and  non-union.     The 


Pig.    15S. 


Fig.    159. 


Fig.   160. 


Fig.   1.57.      Showing  detail  of  vertical  mattress  suture  in  place,  in  the  mucoperiosteal 
flap  from  the  hard  palate. 

Fig.   158.      Showing   detail    of   vertical    mattress    suture    in   place    in    the    velum,      a, 
mucosa  of   nasopharynx  ;   b,    velum   tissue ;    c,    oral    mucosa. 

Fig.   159.      Each  suture  is  used  to  make  the  velum   tense  while  putting  in   the  next 
suture. 

Fig.   160.      The   velum   sutures   are   tightened   before   the    sutures    are    placed    in    the 
mucoperiosteal  flaps.     The  latter  are  all  placed  before  any  of  them  are  tightened. 


use  of  silver  wire  has  the  advantage  that  it  can  be  accurately  twisted 
to  exactly  the  desired  tension.  After  the  operation  the  tissues  will 
swell,  and  allowance  must  be  made  for  this. 

If  the  lead  plates  are  used  in  connection  with  retention  sutures,  the 
packing  should  not  be  left  in  place  after  the  operation  is  completed,  as 
the  palate  flap  is  apt  to  be  constricted  between  the  packing  and  the 


CONGENITAL  PALATE  CLEFTS. 


213 


plate.  In  any  case,  the  packing  should  be  removed  in  twenty-four 
hours,  as  it  promotes  sepsis  and  has  been  responsible  for  extensive 
sloughing.  Care  should  be  exercised  not  to  catch  the  packing  gauze 
in  a  suture,  as  this  would  prevent  its  removal.  It  is  safer  to  remove  it 
before  inserting  the  sutures.  Packing  that  is  to  be  left  in  place  may 
be  saturated  with  a  10  per  cent  solution  of  colloidal  silver  (Crede),  or 
iodoform. 

The  various  steps  of  paring  the  flaps  and  suturing  and  of  applying 
the  retention  sutures  and  lead  plates  are  adequately  explained  by  Figs. 
154  to  162. 


Fig.  161.  Showing  the  method  we  formerly  used  in  placing  lead  plates  for  supple- 
mentary support.  For  reasons  stated  in  the  text,  we  have  abandoned  the  use  of  any 
form  of  supplementary  support  to  the  suture  line. 


When  the  operation  is  finished,  the  pharynx  should  be  sponged  out, 
and  a  careful  inspection  made  to  exclude  active  bleeding.  This  is  done 
by  lowering  the  head,  with  the  patient  turned  well  on  one  side.  Then 
the  blood  would  run  into  the  hollow  of  the  cheek  and  not  collect  in  the 
pharynx. 

RETENTION  DEVICES. 

Before  closing,  it  is  proper  to  review  briefly  the  subject  of  stay 
sutures  and  various  other  supplementary  means  of  protecting  the  suture 
line  and  of  relieving  tension.  It  is  an  absolute  essential  of  the  opera- 
tion that  the  flaps  be  freed  so  that  they  can  be  approximated  without 
tension,  and  there  is  no  contrivance  that  will  compensate  for  a  failure 


214 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


in  this  respect.  It  is  possible,  however,  but  is  by  no  means  universally 
conceded,  that,  after  the  flaps  have  been  properly  freed  and  sutured, 
something  more  can  be  done  by  guarding  against  tongue  pressure,  the 
pull  of  the  palate  muscles,  and  the  strain  of  coughing  and  vomiting. 
Tongue  pressure  may  be  eliminated  by  using  silver-wire  sutures,  the 
ends  of  which  are  allowed  to  point  downward  in  such  a  way  as  to  cause 
discomfort  when  the  tongue  presses  on  the  palate.  Another  device  for 
guarding  against  tongue  pressure,  but  which  can  only  be  used  when 
molar  teeth  are  present,  is  to  have  a  vulcanite  plate  made  that  is  fitted  to 
the  dental  arch  and  which  itself  does  not  rest  against  the  newly  made 
palate.     We  have  never  tried  this  plan  as  it  protects  against  tongue  pres- 


Fig.  162.      The  last  shot  being  crushed  on  the  lead  plate  stay  suture. 


sure  only  and  it  is  not  conducive  to  free  drainage  or  cleanliness.  Pack- 
ing of  the  lateral  incisions  has  been  advised  by  some,  but  this  is  ob^ 
jectionable  because,  if  left  in  place,  the  packing  becomes  foul  and  is 
conducive  to  sepsis  and  even  to  sloughing ;  the  disturbance  of  changing 
would  outweigh  all  of  its  advantages. 

Charles  Mayo  has  advocated  the  use  of  a  piece  of  tape  around  the 
new  palate  through  the  lateral  incisions,  which  is  made  into  a  band 
by  means  of  a  stitch  or  ligature.  In  this  way  the  tissues  are  held  to- 
ward the  median  line  by  the  pressure  of  the  tape  band.  We  have  had 
opportunities  of  observing  very  disastrous  sloughing  from  use  in  less 
skillful  hands.  Judd,  who  now  does  much  of  the  palate  operating  at 
the  Mayo  clinic,  informs  us  that  he  does  not  use  it. 


CONGENITAL  PALATE  CLEFTS.  ai5 

Fillebrown,  Brophy,  and  others  have  devised  modifications  of  the 
old  quill  or  lead  plate  suture,  w^hile  especially  constructed  clamps  have 
also  been  made.  We  formerly  applied  lead  plates,  as  illustrated  in  Figs. 
161  and  162,  but  have  discontinued  their  use,  because  they  occasionally 
caused  sloughing  in  spite  of  every  care.  It  is  our  present  belief,  after 
a  rather  extensive  observation,  that,  although  these  mechanical  adju- 
vants may  be  helpful,  in  some  cases  they  will  cause  sloughing.  We 
have  discarded  them  all,  now  depending  entirely  upon  the  sufficient 
freeing  of  the  flaps. 

AFTER-TREATMENT. 

The  patient  is  given  water  as  soon  after  the  anesthetic  as  desired, 
and  a  purgative  is  administered  as  early  as  possible  to  get  rid  of  the 
blood  that  has  been  swallowed.  Liquid  food  or  soft  jellies  and  gruels 
are  given  for  ten  days,  and  for  the  first  few  days  all  food  and  water 
should  be  sterile.  The  patient  is  not  allowed  to  talk  for  ten  days  or 
two  weeks.  He  is  allowed  to  get  up  on  the  second  or  third  day,  unless 
there  is, fever.  A  mouth  wash  and  a  nasal  douche  are  used  from  the 
first.  In  young  children,  simple  saline  solution  is  used,  but  older  chil- 
dren and  adults  may  use  a  mild  mouth  wash  after  each  feeding  and  fre- 
quently between  times. 

The  alkaline  antiseptic  solution  (N.  F.)  diluted  with  three  parts 
water  makes  an  agreeable  nasal  wash,  which  is  allowed  to  flow  into  the 
nose  from  a  syringe  or  douche  cup,  while  the  head  is  held  erect. 

Lead  plates  may  be  removed  at  the  end  of  two  weeks,  and  the  su- 
tures at  any  time  later.  It  is  not  well  to  make  too  frequent  inspection 
of  the  palate  during  the  first  few  days  following  the  operation ;  and  a 
tongue  depressor  should  not  be  used,  as  it  might  cause  gaping  or  even 
vomiting,  which  would  be  a  strain  on  the  line  of  union. 

POSTOPERATIVE  HEMORRHAGE. 

Our  observations  coincide  rather  closely  with  Mr.  Owens',  in  that 
we  have  but  once  had  serious  hemorrhage  follow  this  operation.  In 
this  case  it  was  controlled  by  packing.  It  seems  to  us  that  the  use  of 
an  anodyne,  packing  the  lateral  incisions,  and,  if  necessary,  allowing 
the  patient  to  sit  up  until  syncope  comes  would  control  hemorrhage  in 
most  any  case,  except  possibly  of  pronounced  bleeders.  If  necessary, 
the  patient  should  be  anesthetized,  the  suture  line  opened,  and  the 
bleeding  point  found ;  or  the  packing  could  be  sutured  in  place. 

NON-UNION. 
Except  where  tape,  packing,  plates,  or  some  other  means  of  reten- 
tion has  been  used,  sloughing  at  any  place,  beyond  the  grasp  of  the 
sutures,  rarely  occurs.    A  mild  grade  of  sepsis  following  the  operation 


216  SURGERY  OF  THE  MOUTH  AND  JAWS. 

is  not  infrequent  and  is  the  usual  cause  of  total  or  partial  failure  after 
a  well-performed  operation.  It  is  evidenced  by  the  persistence  of  a 
temperature  of  101}^°  F.,  or  over,  and  by  a  fetid  odor.  The  sloughs 
fall  away  in  three  to  four  days,  and  if  there  is  a  failure  of  union,  it 
will  usually  be  evidenced  by  this  time. 

Besides  the  use  of  potassium  permanganate  solution  locally,  we 
think  the  use  of  small  doses  of  quinin  and  calomel,  continued  for  twen- 
ty-four or  forty-eight  hours,  is  helpful  in  this  condition. 

REOPERATION. 

After  a  non-union  due  to  sepsis,  Mr.  Owen  recommends  reopera- 
tion at  the  end  of  two  weeks ;  for  at  this  time  the  flaps  are  still  soft, 
and  he  believes  that  the  patient  has  developed  a  resistance  to  the  par- 
ticular infection.  We  have  followed  this  plan  successfully,  but  thought 
there  was  excessive  reaction  following  the  second  operation.  We  cer- 
tainly would  refrain  from  doing  it  in  infants  or  young  children.  Un- 
less there  has  been  extensive  loss  of  tissue,  the  flaps  can  usually  be 
freshened  and  reapproximated  without  difficulty.  In  refreshening  the 
edges  of  the  flaps  for  a  secondary  operation,  the  edges  must  be  de- 
nuded down  to  the  normal  tissue,  as  there  is  at  the  base  of  every  gran- 
ulating surface  a  plane  of  scar  tissue  that  interferes  with  the  rapid 
union  that  is  necessary  for  success.  Small  defects  may  sometimes  be 
made  to  close  by  touching  the  edges  (more  than  once  if  necessary) 
with  the  actual  cautery. 

MORTALITY. 

We  have  had  but  one  fatality  from  this  operation.  In  this  case 
there  was  good  reason  to  believe,  both  from  the  symptoms  and  from 
other  cases  developing  in  the  ward,  that  the  child  died  of  scarlet  fever. 

RESULTS. 

The  later  functional  result  will  depend  both  upon  the  length  and 
mobility  of  the  velum  and  upon  the  ability  of  the  patient  to  develop  the 
use  of  the  superior  constrictor  of  the  pharynx,  and  tongue,  as  aids  of 
the  velum,  which  latter  after  a  late  operation  is  always  short. 

As  a  general  rule,  the  earlier  the  operation  is  performed  the  better 
will  1)e  the  functional  results.    (See  Speech  Training.  Chap.  X\''III.) 


CHAPTER  XVI. 

CONGENITAL  PALATE  CLEFTS— OPERATIONS  FOR 
EXTRAORDINARY  CASES. 

With  very  few  exceptions  all  cases  of  congenital  cleft  palate  can 
be  closed  by  the  original  von  Langenbeck  operation,  described  in  the 
preceding  chapter,  but  in  some  instances  certain  accessory  procedures 
are  advisable  and  even  necessary.  In  a  few  cases,  usually  those  in 
which  large  parts  of  the  tissues  have  been  lost  after  previous  unsuc- 
cessful operations,  it  is  necessary  to  employ  radically  different  meas- 
ures. 

While  the  von  Langenbeck  operation  will  close  almost  every  cleft, 
still,  after  a  child  with  a  cleft  palate  has  passed  the  tenth  or  twelfth 
year,  the  velum  will  not  have  developed  to  the  normal  length.  If  the 
flaps  are  simply  brought  together  in  the  median  line,  inability  to  com.- 
pletely  shut  off  the  nasal  pharynx  usually  results,  which  is  accompa- 
nied by  what  is  recognized  as  the  "cleft  palate"  speech.  As  the  age 
of  the  unoperated  case  increases,  this  deficiency  is  apt  to  become  more 
marked. 

KUSTER'S  OPERATION. 

The  operation  proposed  by  Kiister,  a  modification  of  which  is  illus- 
trated in  Figs.  163  and  164,  to  a  certain  extent  overcomes  this  difficulty 
and  is  advisable  in  all  cases  of  healthy  individuals  who  have  passed 
the  age  of  eight  or  ten  years  and  in  wliom  there  is  sufficient  palate 
tissue  to  allow  its  execution. 

If  the  sum  of  the  available  palate  tissue  is  in  a  proportion  to  the 
width  of  the  palate  of  less  than  5  to  7  (page  19S),  or  even  in  this  or 
near  this  proportion ;  if  the  patient  himself,  or  the  palate  tissues,  are 
not  in  the  best  condition,  one  of  the  two  following  accessory  operations 
will  be  expedient. 

TWO-STEP  OPERATIONS. 

The  simplest  modification  of  the  von  Langenbeck  operation  is  to 
do  it  in  two  steps.  In  the  first  stage  the  mucoperiosteal  flaps  are 
loosened  from  the  bone  through  lateral  incisions,  and  the  velum  is  de- 
tached from  the  posterior  border  of  the  palate  process ;  but  no  incision 
is  made  at  the  cleft  borders.  The  space  between  the  flaps  and  bone  is 
packed  with  gauze  for  a  few  days,  when  the  operation  is  completed  in 

217 


218 


SURGERY  OF  THE  MOUTH  AND   TAWS 


Fig.   163. 


In  Figs.  163  and  164  Kiister  proposed  the  plan  by  means  of  the  incisions  (b-b)  of 
lengthening  the  velum,  but  there  is  rarely  suflBcient  palate  tissue  to  permit  of  this  being 
done  without  leaving  such  wide  gaps  at  the  site  of  the  lateral  Incision  that  subsequent 
scar  contraction  renders  the  velum  too  tense  to  move  freely.  The  figure  shows  a  modifi- 
cation which  obviates  the  latter  dlfllculty.  > 

(a)  shows  incision  at  lateral  border  of  hard  palate  through  the  mucoperlosteum 
(■arried  behind  the  ma.xillary  tubercle  and  straight  out  on  the  buccal  mucosa  for  1  Vj 
centimeters,  then  backward  to  the  level  of  the  lower  jaw,  and  then  inward ;  again  cut- 
ting the  pterygomaxillary  ligament.  The  mucus,  pterygomaxillary  ligament,  and  buc- 
cinator muscle  are  cut  through,  and  the  flap  is  dissected  up  until  the  space  between  the 
internal  pterygoid  and  tensor  palati  muscles  Is  opened.  The  hamular  process  is  cut 
across  at  Its  base. 

The  cleft  borders  of  the  velum  are  not  freshened  in  the  usual  way  ;  but  the  incisions 
(b-b)  are  made  on  each  side  through  the  whole  thickness  of  the  soft  palate,  and  the 
flaps  behind  these  incisions  are  rotated  backward.  In  this  way  the  incisions  (b-b)  are 
opened,  and  the  raw  surfaces  thus  exposed  are  sutured  to  each  other  at  the  median  line 
(Fig.  164).  As  the  two  halves  of  the  velum  are  cariied  toward  the  median  line,  the 
flaps  (a-a)  are  drawn  inward,  and  there  will  be  no  subsequent  scar  contraction  to  render 
the  velum  tense  and  comparatively  useless.  The  space  between  the  upper  and  lower  jaw 
is  still  covered,  and  opening  of  the  mouth  is  but  slightly  interfered  with.  This  opera- 
tion gives  a  longer  velum  than  is  obtained  by  the  simple  von  Langenbeck  operation,  and 
therefore  a  better  functional  result.  It  will  not  permanently  cripple  the  action  of  the 
superior  constrictor  muscle  of  the  pharynx. 


CONGENITAL  PALATE  CLEFTS. 


219 


the  usual  manner.  This  procedure  causes  the  tissues  to  stretch  and 
thicken,  and  also  increases  their  blood  supply.  It  is  our  custom  to  sat- 
urate the  packing  gauze  with  a  10  per  cent  solution  of  colloidal  silver 
(Crede)  and  to  stitch  it  in  place.  It  is  applicable  in  cases  in  which  the 
cleft  is  of  more  than  moderate  width  compared  to  the  available  soft 
tissues  of  the  palate,  and  also  in  cases  where  these  tissues  are  thin  and 
atrophic.  The  objection  to  this  procedure  is  that,  if  for  any  reason 
the  second  operation  cannot  be  performed  within  four  days,  the  pack- 


Fig.  165. 


Figs.   165  and  166.      Showing  amount  that  the  cleft  had   been   narrowed  by   packing 
under  the  flaps  through  lateral  incision. 

ing  must  be  withdrawn.  If  allowed  to  stay  in  longer,  there  will  be 
shrinking  of  the  flaps.  Figs.  165  and  166  are  of  a  case  of  wide  cleft  in 
an  adult  before  and  after  this  step  and  show  the  amount  gained.  Figs. 
167,  168,  and  169  are  of  casts  made  of  this  case  before  the  first  and 
after  the  final  operation.  The  dotted  lines  show  the  exact  location  of 
the  lateral  incisions  w;hich,  where  practical,  were  carried  to  the  outer 
side  of  the  gums.  The  patient  was  forty  odd  years  of  age ;  and  the 
operation  was  done  because  she  was  losing  her  teeth  on  account  of 


220 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


pyorrhea  alveolaris,  and  without  a  restoration  of  the  palate  she  would 
not  be  able  to  wear  artificial  dentures.  This  case  was  one  of  those 
rare  instances  in  which,  although  there  was  complete  palate  cleft,  the 
patient  learned  to  enunciate  almost  perfectl}/  by  using  the  base  of  the 
tongue  against    the  posterior  wall    of  the    pharynx  to    produce  those 


Fig.    167. 


Fig.    168. 


Showing  two  views  of  a  wide  cleft — before  operation — that  was  operated   on    in  two 
stages.      The  dotted  lines  show  the  outline  of  the  lateral  incisions. 


Fig.    169.      Same  case  as  shown  in  preceding  figures  nfter  vlosure  of  the  cleft. 


sounds  that  ordinaril\'  rt'(|uire  llic  closure  of  the  naso[)harynx  by  the 
velum. 

Figs.  170  and  171  are  of  casts  before  and  after  the  closure  of  a  wide 
cleft  in  an  edentulous  mouth  by  this  method.     The  previous  attempts  by 


CONGENITAL  PALATE  CLEFTS. 


221 


the.  ordinary  means  had  been  ahnost  complete  failures.  The  case  was 
that  of  a  tuberculous  adult,  whose  home  surroundings  were  such  that 
without  teeth  she  could  not  get  proper  nourishment.  All  of  the  teeth  in 
both  jaws  had  been  removed  before  we  first  saw  her.  Fig-.  171  shows 
the  final  successful  result. 


Pig.   171. 

Fig.  170.  Sliowing  a  very  wide  cleft  that  was  closed  by  a  two-step  operation  by 
first  packing  under  the  palate  flaps. 

Fig.  171.  Showing  exposed  bone  which  later  became  covered  with  mucosa  drawn 
from  the  neighborhood  by  scar  contraction. 

Another  plan  consists  in  driving  a  chisel  through  the  palate  process 
at  the  ordinary  sites  of  the  lateral  incision  and  forcing-  the  processes 
toward  the  midline.  These  lateral  wounds  are  packed  with  gauze  for 
a  few  days,  when  the  palate  cleft  is  closed  in  the  ordinary  manner. 

APPROXIMATION  OF  THE  MAXILLAE. 

Dt.  G.  V.  I.  Brown,  of  Milwaukee,  and  Prof.  Herman  Schroeder, 
of  Berlin,  have  devised  methods  of  narrowing  the  cleft  in  children  by 


222 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


means  of  orthodontic  apparatus.  Brown  recommends  this  in  cases  of 
eighteen  months  to  two  years  as  a  substitute  for  the  early  Brophy  op- 
eration, while  Schroeder  uses  it  up  to  nine  or  ten  years. 

Figs.  172  and  173  illustrate  a  case  of  a  boy  of  six  years  with  a  cleft 
that  was  wide  in  proportion  to  the  available  palate  tissue.  The  result  in 
three  weeks  is  shown  in  Fig.  173.    The  amount  gained  at  the  posterior 


Fig.    172. 


Fig.    173. 


Showing  plan  of  narrowing  cleft  by  traction.      This   apparatus   was  constructed   and 
applied  at  our  request  by  Dr.  LeGrand  Cox  of  St.  Louis. 


Fig.   174.      Final  result  in  case  shown  in  preceding  illustrations. 

part  of  the  cleft  palate  is  shown  in  numerals,  while  it  will  be  seen  that 
the  projecting  intermaxillary  process  was  pulled  back  into  place  and 
the  aveolar  part  of  the  cleft  approximated.  Fig.  174  shows  the  final 
result  which  was  obtained  without  difficulty  by  the  ordinary  operation. 
After  removing  the  clamps,  the  maxillae  later  spring  back  to  near  their 
original  positions. 


CONGENITAL  PALATE  CLEFTS. 


223 


REPAIR  BY  FLAPS  FROM  OTHER  THAN 
PALATE  SOURCES. 

There  still  remain  those  cases  in  which  much  or  most  of  the  soft 
tissues  covering  the  palate  processes  have  been  lost  from  sloughing  after 
previous  unsuccessful  operation,  and  these  can  only  be  repaired  by 


Fig.    176. 


Showing  method  of  gaining  tissue  from  the  cheek  lining.  Fig.  175  shows  the  in- 
cision that  is  made  at  the  side  of  the  hard  palate  through  the  mucoperiosteum,  carried 
behind  the  maxillary  tubercle,  then  skirting  the  alveolar  process  forward  to  the  an- 
terior border  of  the  masseter  muscle.  It  is  then  carried  outward  in  the  buccal  mucosa 
for  1  centimeter,  and  then  backward.  It  cuts  through  the  mucous  membrane  and  the 
buccinator  muscle,  which  structures  are  raised  in  a  flap  as  far  Inward  as  the  tensor 
palati  muscle.  The  hamular  process  of  the  pterygoid  process  is  fractured  at  its  base. 
As  the  palate  tissues  are  moved  toward  the  median  line,  the  flaps  (a-a)  are  transferred 
to  the  palate,  and  the  defect  in  the  cheek  is  partially  effaced  by  two  sutures.  In  taking 
up  this  cheek  flap,  the  anterior  borders  of  the  ramus  of  the  jaw  and  of  the  internal 
pterygoid  muscles  are  exposed,  and  the  space  between  the  internal  pterygoid  and  tensor 
palati  muscles  is  opened  by  passing  in  a  blunt  instrument  and  pushing  the  velum  toward 
the  median  line.     Fig.  176  shows  the  completed  operation. 


224  SURGERY  OF  THE  MOUTH  AND  JAWS. 

flaps  derived  from  some  extrapalatal  source.  The  following  pro- 
cedures are  applicable  in  certain  cases  where  palate  tissue  has  been 
lost  from  ulceration  or  at  an  operation  for  the  removal  of  a  growth. 

If  the  posterior  border  of  the  velum  has  been  preserved, — and  this 
is  a  part  we  have  never  observed  to  suffer  from  a  postoperative  slough- 
ing— the  velum  and  the  posterior  part  of  the  hard  palate  can  be  recon- 
structed by  the  procedure  illustrated  in  Figs.  17.5  and  17G. 

In  taking  up  the  flaps  in  a  secondary  operation,  any  tissue  that 
immediately  turns  to  a  dark  purplish  red  is  to  be  discarded  at  once,  for 
it  is  granulation  or  scar  tissue  that  will  not  survive  after  being  raised 
from  its  bed.  The  operation  illustrated  in  Figs.  175  and  17G  is  possible 
even  after  lateral  incisions  were  made  at  the  outer  border  of  the  velum 
at  a  previous  operation,  for  the  nutrition  of  the  flap  will  come  from  its 
attached  posterior  part. 

The  cleft  in  the  hard  palate  may  be  restored  by  a  flap  turned  from 
the  buccal  surface  of  the  cheek  or  from  the  neck.  If  there  is  a  hare- 
lip the  border  of  the  lip  cleft  makes  a  convenient  base  for  the  pedicle 
of  the  buccal  flap.  In  a  child  a  fairly  extensive  flap  may  be  taken 
from  the  inner  surface  of  the  cheek  without  causing  any  inconvenience 
or  deformity.  This  flap  should  include  enough  submucous  tissue  to 
insure  the  blood  supply. 

The  plans  of  operation  illustrated  in  Figs.  175  and  17G  are  applicable 
only  in  cases  in  which  some  of  the  mucous  coverings  of  the  palate  has 
been  preserved  on  each  side.  If  this  tissue  has  been  lost  through  the 
whole  of  its  transverse  extent,  then  repair  can  be  made  only  by  means 
of  a  flap  obtained  from  an  extraoral  source.  If  this  is  the  case,  the 
edges  of  the  defect  and  the  scar-covered  surfaces  of  the  palate  pro- 
cesses are  denuded,  and  special  care  is  taken  to  remove  all  scar  bands 
that  draw  the  velum  forward.  It  is  just  as  easy  to  fill  a  large  gap  as 
a  small  one  with  a  flap  from  the  neck,  and  the  longer  the  palate  the 
better  the  result.  (For  general  plan  of  making  the  neck  flap,  see  page 
25:3.) 

In  planning  the  length  of  the  flap,  it  is  to  be  remembered  that  it 
must  reach  from  the  lower  border  of  the  cheek  to  the  roof  of  the 
mouth  and  then  to  the  edge  of  the  palate  defect  without  tension  while 
the  mouth  is  partially  open.  If,  after  the  flap  has  been  fastened,  it  is 
found  to  be  too  short,  it  may  be  lengthened  by  extending  the  cuts  up- 
ward on  the  cheek,  but  this  will  leave  scars  in  a  conspicuous  place. 
There  will  be  no  question  about  its  antero-posterior  extent,  for  the  flap 
should  be  made  nearly  5  centimeters  wide  to  insure  the  blood  supply. 
The  flap  is  sutured  with  silkworm  gut  or  silver  wire,  skin  edge  to 
mucous  edge,  across  the  anterior  border  of  the  velum,  the  lateral  bor- 
der of  the  defect  of  the  side  opposite  to  that  from  which  the  flap  is 


CONGENITAL  PALATE  CLEFTS. 


225 


turned,  and  across  the  posterior  border  of  the  remaining  mucous  tissue 
of  the  hard  palate.  These  sutures  should  not  be  too  numerous  or 
drawn  tight.  Eight  or  ten  days  later  the  flap  may  be  cut  across  at  the 
palate  border,  and  the  pedicle  again  turned  on  to  the  neck  for  the  re- 
pair of  the  upper  part  of  the  external  wound. 

Before  the  flap  is  cut  across,  it  is  well  to  test  the  local  blood  sup- 
ply of  the  implanted  part  by  gently  constricting  its  base  with  a  pair 
of  forceps. 

While  the  flap  is  in  place,  until  the  base  is  cut,  the  jaws  must  be 
held  apart  to  prevent  the  teeth  from  shutting  off  the  blood  supply. 
This  may  be  done  by  wiring  a  block  of  wood  or  a  piece  of  a  rubber 
stopper  between  the  bicuspid  teeth  on  one  side.  It  is  very  much  safer 
and  more  satisfactory,  however,  to  have  an  accurately  fitting  piece  of 


Fig.    177.  Pig.    178. 

Showing  extension  defect  resulting  from  postoperative  sloughing,  and  the  result  ob- 
tained by  the  use  of  a  flap  from  the  neck. 

metal,  made  beforehand  by  a  dentist,  which  is  fastened  by  wires  to 
rings  on  tooth  bands  above  and  below. 

Fig.  177  shows  condition  after  a  second  failure  with  extensive  post- 
operative sloughing,  following  attempts  to  close  the  cleft  by  the  von 
Langenbeck  operation. 

Fig.   178  shows  restoration  by  the  method  just  described. 

Fig.  179  shows  the  neck  flap  in  place  in  the  mouth  before  being  cut 
loose.  Fig.  180  shows  the  condition  of  the  neck  one  week  after  the 
flap  was  taken  from  the  neck,  but  before  the  pedicle  was  released  from 
the  mouth. 

Owing  to  the  abundance  of  tissue  obtained,  this  gives  a  longer 
velum  and  a  better  functional  result  than  is  ordinarily  obtained  in 
adults  by  the  von  Langenbeck  operation.  It  leaves  but  a  linear  scar 
to  show  where  the  tissue  has  been  removed  from  the  neck.     In  a  num- 


226 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


ber  of  cases  where  we  have  resorted  to  skin  flaps  from  the  neck  for  the 
repair  of  mouth  and  palate  defects,  no  inconvenience  has  been  observed 
as  a  result  of  transplanting  skin  into  the  mouth.  It  soon  takes  on  an 
appearance  which  closely  resembles  normal  mucous  membrane. 

In  one  case  we  successfully  resorted  to  this  method  in   restoring 
part  of  the  velum,  the  fauces  of  one  side,  and  part  of  the  oral  pharynx, 


Fig.   179.      Shows    permanent    gag    in    place,    and    neck    flap    sutured    into    the    palate 
defect. 


Fig.  180.  Show.s  neck  defect  almost  entirely  obliterated  by  drawing  the  skin  edges 
together.  The  upper  triangular  defect  still  remaining  is  closed  with  the  pedicle  of  the 
flap,  after  it  is  cut  and  withdrawn  from  the  mouth.     . 


after  an  excision  of  a  malignant  growth.  In  another  we  failed  to 
close  a  palate  defect  after  taking  a  flap  from  both  sides  of  the  neck  in 
turn,  owing  to  progressive  sloughing  of  the  flap.  This  was  in  a  syphil- 
itic child. 

The  idea  of  repairing  palate  and  other  intraoral  defects  with  epi- 
thelial tissue  from  other  sources  is  not  new;  Blaisus,  Thiersch,  Rotter, 
and  other  surgeons  having  reported  such  cases. 


CHAPTER  XVII. 

CONGENITAL  CLEFTS  OF  THE  LIP  AND  ALVEOLAR 

PROCESS— OPERATIVE  CORRECTION. 

Cleft  of  the  lip  and  cleft  of  the  alveolus  are  presented  together, 
because  the  latter  seldom  occurs  in  the  absence  of  the  former  and  be- 
cause, surgically,  the  closure  of  the  alveolus  is  related  more  intimately 
to  closure  of  the  lip  cleft  than  to  the  palate  cleft  when  the  latter  is  pres- 
ent. In  the  presence  of  cleft  palate  there  is  nearly  always  at  least  an 
occult  bony  cleft  in  one  or  both  sides  of  the  alveolus.  This  is  some- 
times evidenced  by  a  simple  irregularity  of  the  teeth  or  a  notch. 

In  discussing  the  treatment  of  alveolar  cleft  it  is  convenient  to  do 
so  as  follows :  single  or  double  clefts  in  young  infants ;  single  cleft  at 


Fig.  181.  Showing  a  condition  in  which  the  end  of  the  alveolar  process  to  the 
outer  side  of  an  alveolar  cleft  is  situated  behind  the  intermaxillary  bone.  To  correct 
this,  the  end  of  the  alveolar  process  of  the  maxilla  must  be  loosened  and  pushed  out- 
ward, as  shown  in  the  second  figure,  before  the  intermaxillary  bone  can  be  replaced. 

later  periods;  and  double  cleft  at  a  later  period.  In  each  the  follow- 
ing rule  holds  true :  The  intermaxillary  bone  is  never  to  be  removed 
but  is  to  be  placed  in  the  best  attainable  position,  usually  the  cleft  bor- 
ders being  denuded  to  the  bone  so  that  raw  surfaces  will  be  in  contact 
when  the  gap  in  the  process  is  closed.  When  the  process  is  replaced, 
the  attachment  of  the  nasal  septum  and  columella  should  be  in  the  mid- 
line. After  early  infancy  some  orthodontic  procedure  may  be  necessary 
to  draw  together  the  borders  of  the  alveolar  cleft.     This  can  usually, 

227 


228 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


but  not  always,  be  accomplished  by  repairing  the  lip  over  the  alveolar 
cleft;  but  this  gives  a  difficult  lip  repair  and  usually  a  defined  nostril. 
(See  Figs.  182  and  183. )  The  alveolar  process  should  never  be  cut 
with  a  chisel  to  close  this  cleft  in  older  children. 

CORRECTION  OF  ALVEOLAR  CLEFTS  IN  INFANTS. 

The  alveolar  cleft,  as  well  as  the  lip.  should  be  repaired  at  the  same 
time  as  the  Lane  or  Brophy  operation  is  performed.  The  latter  opera- 
tion usually  consists  in  little  more  than   reestablishing  the  continuity 


A 


B 


a 


Fig.  182.  The  first  cast  (A)  shows  a  wide  unrepaired  cleft  at  the  age  of  eighteen 
months.  The  cleft  is  partially  filled  by  a  transverse  part  of  the  nasal  septum  that 
would  prevent  the  maxillary  bones  from  being  drawn  together.  At  the  first  operation 
this  transverse  part  of  the  nasal  septum  was  removed  and  the  palate  repaired  by  a 
.von  Langenbeck  operation.  As  a  result  of  the  traction  of  the  soft  tissues  across  the 
bony  cleft  the  palate  became  narrower,  shown  in  cast  (B)  made  three  months  later, 
but  there  was  still  a  wide  alveolar  separation.  Dr.  F.  J.  Brockman  constructed  the 
orthodontic  appliance  shown  on  cast  (B),  with  which,  by  means  of  an  elastic  band,  the 
alveolar  cleft  was  clcsed  in  two  weeks,  as  shown  in  cast  (C).  Then  the  lip  repair  was 
made. 


Fig.   18.3.      Showing  the  obliteration  of  the   alveolar  cleft  by  means  of   an  expansion 
arch   by  Brockman.     Fig.   18.3C  shows  the  final  lip   repair  over  the  closed   alveolar  cleft. 

of  the  alveolus,  and  we  doubt  whether  any  more  extensive  bone  shifting 
is  ever  necessary  or  always  advisable.  In  early  infancy  it  is  not  neces- 
sary to  cut  the  nasal  septum  in  order  to  replace  the  intermaxillary  bone. 
If  the  cleft  is  limited  to  the  alveolar  process,  it  may  be  necessary  to 
remove  or  incise  some  of  the  palate  process  of  the  maxilla,  just  behind 
the  cleft,  before  the  protrusion  can  be  pushed  back  into  line.     This  is 


CLEFTS  OF  LIP  AND  ALVEOLAR  PROCESS. 


229 


done  submucoperiosteally  with  a  small  chisel  or  bone  forceps.  In 
some  cases  the  alveolar  process  to  the  outer  side  of  the  cleft  will 
have  traveled  toward  the  median  line,  and  it  is  necessary  to  pry  it 
outward  in  order  to  make  room  for  the  intermaxillary  process  (Fig. 

181). 

CORRECTION  OF  SINGLE  ALVEOLAR  CLEFTS  AT 
LATER  PERIODS. 

Before  six  months,  when  there  is  also  a  palate  cleft,  the  protruding 
process  can  be  pushed  back  by  thumb  pressure.     In  older  children  the 

protruding-  process  should  be  brought  back  into  place  by  an  orthodontic 
apparatus    (Figs.   173  and   173).     Many   surgeons   simply  repair   the 


Pig.  184.  Complete  double  cleft  in  an  infant.  White  line  shows  where  the  mucous 
membrane  is  incised  at  the  lower  border  in  order  to  remove  a  V-shaped  piece  from  the 
septum. 

lip,  depending  upon  the  pressure  of  the  lip  to  force  the  process  back 
into  place.  We  do  not  believe  this  is  to  be  recommended  because  of 
the  difficulty  of  making  a  satisfactory  lip  repair  over  the  protruding 
process. 


CORRECTION   OF   DOUBLE  ALVEOLAR  CLEFTS  AT 
LATER  PERIODS. 

In  double  complete  cleft,  the  intermaxillary  process  travels  forward 
at  the  expense  of  the  columella ;  and  to  replace  it  after  early  infancy, 


230 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  septum  must  be  incised  behind  the  intermaxillary  bone,  or  a  V- 
shaped  section  must  be  removed  at  this  site  (Figs.  184,  185,  and  186). 
This  shortening  of  the  columella  is  more  apparent  than  real,  and 
usually,  in  replacing  the  intermaxillary  bone,  it  has  been  inoved  too  far 


Fig.    185. 


Fig.    186. 


h0^ 

^H 

H^w.> 

hI^ 

y    JWKm 

Hi^^' 

^^c^ 

Hjiiiifc,, 

Fig.   187. 

Fig.  185.  Showing  prominence  of  intermaxillary  bone  and  short  columella.  In- 
fant of  9  months. 

Fig.  186.  Showing  same  condition  as  the  preceding  illustration.  Child  5  years 
old.     This  condition  will  persist  as  long  as  the  lip  cleft  is  unrepaired. 

Fig.  187.  Showing  the  drawing  in  of  the  nose  after  replacing  a  protruding  inter- 
maxillary process.  This  condition  improves  very  much  in  time,  and  the  earlier  the  op- 
eration is  done  the  better. 

back.  The  result  of  this  is  that  the  end  of  the  nose  is  drawn  in  and 
the  intermaxillary  is  rotated  until  the  contained  incisor  teeth  point  some- 
what backward.  Only  a  very  small  section  should  be  removed  from  the 
nasal  septum,  and  in  repairing  the  lip,  the  lateral  portions  should  be 
brought  forward  to  the  apparently  still  prominent  prolabium.    This  will 


CLEFTS  OF  LIP  AND  ALVEOLAR  PROCESS. 


231 


preserve  the  prominence  of  the  Hp  and  partially  prevent  the  flat  ap- 
pearance that  is  so  frequently  seen  after  an  operation  for  double  cleft 
of  the  lip  and  alveolus  (Fig.  187).  In  young  infants  this  is  not  diffi- 
cult to  do,  but  later  there  are  intraoral  conditions  that  may  make  it  im- 
practicable to  get  immediate  union  between  intermaxillary  and  palate 
parts  of  the  alveolus.  As  a  rule,  some  of  the  alveolar  tissue  is  missing, 
so  that  in  order  to  obtain  firm  bony  union  between  the  intermaxillary 
and  the  maxillary  bones  it  is  necessary  to  place  the  former  farther  back 
than  it  belongs.  In  young  infants  the  anterior  part  of  the  two  halves  of 
the  palate  can  be  approximated  by  a  Brophy  operation  so  that  the  in- 
termaxillary will  sit  in  front  of,  rather  than  between,  the  maxilla.  At 
later  periods  it  is  better  simply  to  set  the  intermaxillary  bone  back  to 
its  proper  position  without  denuding  the  cleft  borders.  After  the  lip 
wound  has  healed,  an  electric  or  Paquelin  cautery  blade  may  be  thrust 
into  the  cleft  on  either  side.  If  the  lining  mucosa  is  destroyed,  this 
will  be  followed  by  bony,  or  strong  fibrous,  union. 

CORRECTION  OF  HARELIP. 

We  repair  the  lip  at  the  same  time  as  the  alveolar  cleft.     There 
have  been  so  many  various  operations  proposed  for  the  repair  of  hare- 


Fig.   188.      Showing  construction  of  nostril,  that  may  oicur  from   an  infolding  of  the 
upper  part  of  the  ala. 


lip  that  one  seeking  help  from  the  surgical  textbooks  is  likely  to  be 
confounded  by  the  wealth  of  ideas  suggested.  But  four  will  be  pre- 
sented here,  for  the  reason  that  one  of  the  number  will  be  found  ade- 
quate for  almost  every  case,  and  that  we  believe  they  will  not  only  give 
the  best  results,  but  the  plan  of  each  of  these  is  easily  carried  out. 
Among  others,  we  have  discarded  the  time  honored  Nelaton  operation 
because  it  will  seldom  give  an  accurate  result. 


232  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Regardless  of  the  plan  of  operation  chosen,  it  is  a  good  practice  to 
outline  the  cuts  by  scratching  on  the  skin  with  the  point  of  a  knife  be- 
fore actually  making  the  incisions,  and  the  use  of  some  sort  of  a  meas- 
ure or  of  a  pair  of  compasses  will  give  greater  accuracy.  In  this  way 
one  is  not  confused  by  the  flow  of  blood,  as  may  be  the  case  when  he 
attempts  to  plan  and  cut  at  the  same  time.  It  is  very  pretty  to  watch 
a  skilled  operator  make  his  flaps  with  two  or  three  quick  cuts,  but  the 
average  surgeon  will  get  far  better  results  by  the  method  suggested 
above.  It  is  usually  necessary  to  undermine  the  lip  in  order  that  it 
may  slide  over  to  its  new  position  without  tension.  The  lateral  seg- 
ment of  the  lip  is  often  closely  attached  to  the  alveolar  process  by  a 
sort  of  frenum;  this  is  cut,  and  the  lip  and  cheek  are  freed  from  the 
maxilla  with  an  elevator  that  hugs  the  bone  closely.  If  necessary,  the 
opening  in  the  mucosa  at  the  fornix  may  be  enlarged.  The  ala  should 
not  be  freed  higher  than  is  necessary  as  when  it  is  entirely  detached  it 
tends  to  fold  inward  and  to  obstruct  the  nostril  (Fig.  188). 

An  almost  absolute  essential  to  the  making  of  accurate  incisions  is 
a  thin  narrow-bladed  knife  that  has  an  edge  so  sharp  and  smooth  that 
it  will  not  drag  on  the  lip  in  cutting.  After  the  flaps  have  been  out- 
lined, before  the  cuts  are  made,  at  least  in  infants,  hemorrhage  should 


Fig.    189.      Showing    method    of    partially    controlling    hemorrhage    while    paring   the 
cleft  borders. 

to  a  certain  extent  be  controlled.  This  is  done  by  grasping  each  half 
of  the  lip  with  a  pair  of  straight-sided  tenaculum  forceps  that  are  held 
tight  enough  to  constrict  the  tissues  without  crushing  them;  artery 
forceps  may  be  snljstitiited  for  these  (Fig.  180).  The  intraoral  prong 
of  each  pair  of  forceps  is  thrust  through  the  mucous  membrane  at  the 
upper  fornix  and  into  the  tissues  of  the  face. 


CLEFTS  OF  LIP  AND  ALVEOLAR  PROCESS. 


233 


ROSE  OPERATION. 

This  consists  of  the  removal  of  a  semioval-shaped  piece  from  each 
side  of  the  lip  cleft  so  that  when  the  two  concave  raw  surfaces  are 
pulled  straight  and  approximated  the  lip  notch  is  obliterated.  The 
originator  of  this  operation  used  it  for  all  sorts  of  clefts,  but  it  is  espe- 
cially appropriate  for  cases  of  partial  cleft,  for  notches  remaining  after 
previous  operations,  and  for  cases  of  complete  harelip  in  which  little 
of  the  lip  tissue  is  missing.  It  has  the  virtue  of  simplicity  and  is  easily 
performed  (Fig.  190).  In  making  the  incisions,  the  following  points 
are  to  be  borne  in  mind : 

1.  The  full  thickness  of  the  lip  is  to  be  incised,  no  more  being  taken 
from  the  cutaneous  than  the  inner  surface,  and  vice  versa. 


Fig.    193. 


Fig.    194. 


Fig.  190.  Outlines  of  incision  in  a  Rose  operation  for  partial  lip  cleft,  in  which 
there  is  also  a  spreading  of  the  nostril  of  that  side.  By  the  vertical  dotted  lines  it  Is 
seen  that  the  Incisions  extend  laterally  as  far  as  the  widest  part  of  the  cleft.  It  will 
also  be  seen  that  the  length  of  each  cut  within  the  vermilion  border  of  the  lip  is  the 
same.  If  the  lengths  of  the  two  curved  incisions  were  measured,  it  would  be  found  that 
they  were  of  the  same  length  on  each  side.  These  are  the  three  important  points  in 
designing  the  incisions  of  a  Rose  operation. 

Fig.   191.      Incisions  for  Rose  operation  of  a  complete  single  cleft. 

Fig.  192.  After  making  the  incisions  for  the  Rose  operation,  the  ala  is  replaced 
with  one  suture,  and  the  newly  pared  borders  are  approximated  and  put  on  the  stretch 
by  a  tension  suture  placed  at  the  mucocutaneous  border. 

Fig.   193.     Rose  operation  for  double  harelip,  incomplete  on  one  side. 

Fig.   194.      Completed  Rose  operation  for  double  harelip. 

2.  The  incision  must  traverse  the  mucous  border  of  the  lip  at  a 
place  where  the  latter  is  of  the  full  normal  breadth.  Sometimes  close 
to  a  lip  notch  the  mucous  border  is  narrower  than  at  the  other  parts. 

3.  The  convexity  of  the  lip  incisions  on  each  side  of  the  cleft  must 
extend  laterally  as  far  as  the  widest  part  of  the  cleft,  which  latter  is 


234 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


always  at  the  lip  border  (Figs.  190  to  19 J:).  When  the  new  lip  is  com- 
pleted, there  must  be  a  teat  at  the  lower  end  of  the  suture  line.  This 
is  to  allow  for  scar  contraction,  In  this,  as  in  other  operations,  the 
borders  to  be  united  are  approximated  by  stay  sutures  at  each  end; 
by  drawing  upon  these,  slight  inequalities  in  length  between  two  bor- 
ders are  thus  equalized  (Fig.  192).  The  outer  surface  and  red  border 
of  the  lip  are  united  by  a  fine  continuous  running  suture  that  includes 
only  the  skin  or  mucosa.  The  deep  approximation  is  made  with  one 
or  two  modified  Lane  sutures  (Fig.  19).  The  Rose  operation  is  par- 
ticularly adapted  to  the  correction  of  the  result  of  a  poor  operation 
(Figs.  195  and  196). 


Pig.    195. 


Pig.    196. 


Pig.  195.  Cast  of  lip  and  uose  of  a  girl  sixteen  years  old,  who  had  a  very  poor 
operation  done  at  three  years. 

Fig.  196.  Same  case  as  shown  in  preceding  figure.  Cast  made  some  months  after 
a  Rose  operation. 

OWEN  OPERATION. 

This  is  more  appropriate  for  single  clefts  with  widely  diverging 
borders,  and  is  the  one  we  prefer  for  most  cases  of  complete  single  hare- 
lip. When  properly  done,  this  gives  a  very  good  lip  that  is  not  tight 
at  its  lower  border,  and  as  the  scar  crosses  the  mucous  border  at  the 
angle  of  the  mouth,  it  is  not  very  noticeable.  The  incisions  and  the 
manner  of  suturing  are  shown  in  Figs.  197,  198,  and  199.  The  traiis- 
verse  incisions  are  usually  made  about  midway  between  the  mucocu- 
taneous border  and  the  nose.  As  with  the  Rose  operation,  it  is  im- 
portant that  the  incision  traverses  the  lip  in  such  a  way  that  it  is  the 
same  distance  from  the  lip  or  cleft  border,  on  the  cutaneous  as  on 
the  mucous  surface. 

OPERATION  FOR  DOUBLE  HARELIP. 

For  those  cases  in  which  the  cleft  is  complete  on  one  side  but  par- 
tial on  the  other,  we  use  the  Rose  operation  (Fig.  19:]).  For  complete 
double  harelip  where  the  clefts  have  a  complete  mucous  border,  the 
plan  shown  in  Figs.  200  and  201,  is  simple  and  satisfactory. 


CLEFTS  OF  LIP  AND  ALVEOLAR  PROCESS. 


235 


Fig.  197.  Incisions  for  the  Owen  operation  on  a  single  harelip.  The  important 
points  are  to  make  the  transverse  cut  parallel  with  the  mouth  slit ;  to  make  (a-b)  equal 
to  (a'-b')  ;  so  to  place  the  point  (b)  that  the  flap  will  be  of  the  proper  width  to  fill  the 
gap  below  (b'). 

Fig.  198.  Owen  operation.  Nostril  has  been  approximated  by  one  deep  suture,  and 
the  borders  of  vertical  part  of  the  cleft  by  another,  at  their  lower  end.  The  latter  is 
used  as  a  traction  suture  to  approximate  and  make  even  the  cleft  borders  while  the 
superficial  sutures  are  put  in  place. 

Fig.   199.      Owen  operation  for  single  harelip.     Suturing  of  the  transverse  incision. 


200. 


Fig.   200.      Operation   we    use    for    complete    double    harelip.      The    tissue    within    the 
cuts   (c,  d,  a)   is  discarded  on  each  side,  as  is  the  border  of  the  prolabium. 
Fig.   201.      Operation  for  complete  double  harelip  completed. 


236  SURGERY  OF  THE  MOUTH  AND  JAWS. 

After  operation  no  dressing  but  a  dusting  powder  is  placed  on  the 
suture  line,  or  it  is  painted  with  alcohol  or  colloidal  silver. 

After  completing  any  operation  for  harelip,  some  plan  should  be 
adopted  to  take  off  the  pull  of  the  buccinator  muscles.  Several  plans 
of  doing  this  have  been  used;  one  is  simply  to  place  a  single  strip  of 
adhesive  plaster  across  the  lip  and  cheeks  from  ear  to  ear.  To  avoid 
placing  the  adhesive  plaster  across  the  lip  wound,  common  dress  hooks 
may  be  sewed  on  the  ends  of  the  two  shorter  strips,  one  set  of  the 
hooks  resting  on  each  side  of  the  lip  wound.  These  are  laced  to- 
gether with  silk  thread.  This  will  not  prevent  slipping  of  the  ala  of 
the  nose,  and  even  silk  threads  resting  over  the  lip  wound  are  objec- 
tionable; therefore  the  transverse  straps  have  been  rather  generally 
abandoned.  Placing  narrow  strips  of  adhesive  plaster  from  under  the 
chin,  around  the  cheek,  across  the  bridge  of  the  nose,  and  on  to  the  fore- 
head on  both  sides  will  draw  the  cheeks  toward  the  nose  and  somewhat 
relieve  the  strain.  It  has  the  advantage  of  not  covering  the  lip,  but 
it  will  not  entirely  prevent  spreading  of  the  nostrils.  These  straps 
should  be  retained  and,  when  they  slip,  replaced  for  eight  or  ten  days. 
Twice  we  have  seen  a  well-placed  nostril  spread  wide  open  on  the  fifth 
or  seventh  day  when  the  straps  were  prematurely  removed.  On  ac- 
count of  the  occasional  slipping  of  the  ala,  even  with  these  straps,  we 
have  adopted  Gilmer's  modification  of  Garretson's  use  of  lead  plates 
(Fig.  202). 

CORRECTION  OF  DEFORMITY  OF  THE  NOSTRIL 

AND  NOSE. 

In  repairing  a  harelip,  the  restoration  of  the  nostril  and  ala  is 
usually  the  most  difificult  part  of  the  operation.  Even  in  cases  of  slight 
lip  notch  there  is  usually  some  spreading  of  the  nostril  with  a  displace- 
ment of  the  columella,  septum,  and  tip  of  the  nose  to  the  opposite  side; 
in  complete  single  cleft  the  ala  of  that  side  may  be  absolutely  flat,  with 
a  still  greater  displacement  of  the  septum  and  nose.  In  double  hare- 
lip the  nose  remains  in  the  midline,  but  both  alae  are  spread  laterally. 
In  planning  the  incisions,  we  aim  to  make  the  inlet  of  the  nostrils 
smaller  than  normal,  for  it  usually  happens  that,  in  spite  of  careful  ap- 
proximation and  suturing,  the  ala  slips  and  the  nostrils  widen  within 
a  week.  The  incision  is  made  close  to  the  lower  border  of  the  ala,  but 
the  least  possible  amount  of  tissue  is  removed  from  within  the  nos- 
tril ;  for  it  is  easy  to  block  the  nostril  by  an  infolding  of  the  upper  bor- 
der of  the  ala  cartilage  (Fig.  LSS).  If  this  occurs,  the  impinging  part 
of  cartilage  may  be  removed  submucously.  Often,  immediately  after 
suturing  the  ala  in  babies,  the  external  opening  is  reduced  to  a  mere 


CLEFTS  OF  LIP  AND  ALVEOLAR  PROCESS. 


237 


slit  or  is  completely  closed ;  but  this  begins  to  open  in  a  few  days,  and 
gradually  the  proper  shape  of  the  nostrils  is  restored.  If,  however, 
the  nostril  is  blocked  by  an  infolding  of  the  upper  border  of  the  ala 
cartilage,  it  never  completely  corrects  itself.  To  prevent  slipping  of 
the  ala,  after  it  has  been  properly  placed,  is  difficult,  some  slipping  oc- 
curring in  most  cases.  In  addition  to  careful,  deep  suturing,  so  far, 
the  most  effective  plan  we  have  tried  has  been  the  lead  plates  (Fig. 
202).  These  must  be  placed  a  little  distance  from  the  ala  and  are  held 
in  place  with  a  shotted  silver  wire. 

In  reoperating  on  a  case  in  which  the  nostrils  spread,  the  ala  is  dis- 
sected loose  from  the  cheek  and  replaced  after  removing  a  diamond- 


Pig.  202.  Showing  lead  plates  on  cheek.  Through  these  is  passed  a  silver  wire 
that  traverses  the  tissues  of  the  face  above  the  level  of  the  lower  border  of  the  alae. 
These  wires  are  shotted. 

shaped  piece  from  the  floor  of  the  nostril  and  upper  part  of  the  lip. 
If  the  ala  is  much  spread  in  an  adult  or  older  child,  we  have  found  it 
expedient  not  only  to  free  the  ala  from  the  maxilla  but  also  to  carry 
an  incision  outward  just  below  the  ala  out  through  the  full  thickness 
of  the  cheek  for  15  millimeters ;  this  usually  allows  of  easier  adjustment 
of  the  ala. 

In  young  infants  the  columella,  the  septum,  and  the  nose  itself  will 
be  drawn  to  the  midline  when  the  intermaxillary  bone  is  restored  to 
its  proper  position.     When  the  lip  cleft  has  been  allowed  to  persist, 


238 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


unoperated,  or  only  partially  obliterated,  the  external  nose  and  septum 
become  permanently  distorted;  the  columella  can  be  drawn  over  with 
the  lip,  but  the  lower  anterior  part  of  the  septum  with  the  external  nose 
will  remain  in  its  lateral  position.     When  this  distortion  is  sufficient  to 


Fig.  203.  Correction  of  a  deflected  septum.  Dotted  line  shows  line  of  incision 
through  septum,  made  with  hooked  knife.  Chisel  in  place  shows  how  the  bone  of  the 
septum  is  cut  from   the  maxilla. 


Fig.  204.  Correction  of  a  deflected  septum.  The  septum  having  been  freed,  as 
shown  in  the  preceding  figure,  it  is  anchored  in  its  new  position  to  a  bicuspid  tooth  with 
silver  wire. 


be  noticeable  or  causes  partial  nasal  obstruction,  it  may  be  corrected  as 
follows : 

Through  the  upper  fornix,  the  lip  is  dissected  up  as  far  as  the 
lower  part  of  the  anterior  nasal  spine  of  the  maxilla.     A  chisel  with  a 


CLEFTS  OF  LIP  AND  ALVEOLAR  PROCESS. 


239 


blade  about  1  centimeter  broad  is  placed  against  the  base  of  this  spine ; 
it  and  the  lower  part  of  the  septum  are  cut  straight  backward  for 
about  4  or  5  centimeters.  With  a  small  hooked  septum  knife,  the  sep- 
tum is  again  cut  completely  through  from  near  the  nasal  spine  of  the 
frontal  bone  vertically  downward  to  intersect  the  first  cut  (Fig.  203). 
Having  freed  a  triangular  flap  of  septum,  a  thin,  soft-silver  wire  is 
passed  through  the  lower  part  of  the  septum  near  the  nasal  spine,  and 
the  septum  and  spine  are  held  in  their  proper  position  by  anchoring  this 
wire  to  a  bicuspid  tooth  (Fig.  204).  This  will  draw  the  septum  and 
the  tip  of  the  nose  to  the  midline.  If  the  nasal  bones  share  in  the 
deviation  to  a  marked  extent,  they  may  be  brought  over  by  laying  a 
thickly  folded  towel  against  one  side,  fracturing  the  bones  by  striking 
them  with  a  mallet. 


Fig.  205.  Correction  of  deflection  of  the  nose.  Diagram  showing  a  displaced  nose 
held  In  its  new  position  by  a  silver  wire  passing  from  the  nasal  bone  on  one  side  through 
the  septum,  nasal  cavities,  and  soft  tissues  of  the  cheek,  and  anchored  to  a  molar  tooth 
of  the  opposite  side. 

This  plan  of  replacing  a  deviated  nose  was,  as  far  as  we  know,  first 
practiced  by  Dr.  E,  M.  Senseny,  and  we  have  found  it  fairly  satis- 
factory. If  the  nasal  bones  are  not  prominent,  especially  in  children, 
we  cut  the  nasal  bones  en  masse,  subcutaneously  from  the  maxillary 
and  frontal  bones.  This  is  done  by  inserting  a  narrow  straight  chisel 
into  each  nostril,  in  turn,  and  applying  the  edge  to  the  junction  of  the 
lower  border  of  the  nasal  bones  with  the  maxillae.  It  is  driven  up- 
ward on  each  side,  as  high  as  the  frontal  bone.  The  chisel  is  guided 
by  feeling  one  corner  under  the  soft  tissues  of  the  face  as  it  travels 
upward.  The  attachment  of  the  nasal  bones  to  the  frontal  is  not  cut 
entirely  through.  The  nose  is  shifted  in  its  proper  position  by  thumb 
pressure.  To  hold  the  nose  in  the  proper  position,  two  holes  are  drilled 
through  the  skin  and  nasal  bones  on  the  side  to  which  the  nose  has 
deviated.     The  two  ends  of  a   No.  24  soft-silver  wire  are,  in  turn. 


340  SURGERY  OF  THE  ^lOUTH  AND  JAWS. 

threaded  with  a  long,  straight  needle  and  passed  through  the  two  holes 
in  the  bone,  through  the  nasal  chambers  and  septum,  through  the  tis- 
sues of  the  cheek,  into  the  vestibule  of  the  mouth  in  front  of  the  last 
upper  molar  tooth.  Here  they  are  anchored  at  proper  tension  to  a 
wire  band  on  the  last  upper  molar  (Fig.  205).  By  incising  the  skin 
down  to  the  bone  between  the  two  drill  holes,  the  external  loop  of  the 
wire  becomes  buried.  This  is  the  only  satisfactory  plan  we  have  ever 
tried  for  holding  the  nose  in  position.  In  our  hands,  external  appli- 
ances have  been  very  unsatisfactory.  We  also  use  this  plan  for  read- 
justing the  nose  after  a  malunion  from  fracture. 

DIFFICULT   RESPIRATION   AFTER  A   LIP   OPERATION. 

It  often  happens  that,  after  an  operation  for  harelip,  especially  in 
an  infant,  there  is  difficult  respiration,  evidenced  by  restlessness  and 
by  sucking  in  of  the  lips  at  each  inspiration.  If  this  is  not  relieved, 
the  child  emaciates  rapidly,  and  we  believe  this  has  been  the  cause  of 


Fig.  206.  Breathing  tube  made  of  soft  one-fourth-inch  gum  tubing,  to  be  used  in 
case  of  difficult  respiration  after  operation  for  harelip.  The  tube  is  Inserted  in  the 
mouth  and  above  the  tongue,  and  the  tapes  are  tied  behind  the  head. 

postoperative  depression  in  some  of  our  earlier  cases.  Suturing  down 
the  lower  lip  is  seldom  satisfactory,  and  we  have  resorted  to  the  prac- 
tice of  using  a  breathing  tube  (Fig.  206)  in  every  case  of  harelip  opera- 
tion in  an  infant.  The  tube  is  removed  at  first  only  for  feeding;  but 
usually  after  a  few  days  the  nostrils  become  free,  and  the  breathing 
tube  may  be  dispensed  with. 

AFTER-TREATMENT. 

The  wound  is  covered  with  a  simple  dusting  powder,  and  crusts  are 
not  allowed  to  collect.  If  retention  straps  are  used,  they  are  read- 
justed when  needed,  and  retained  for  nine  days.  The  child  must  be 
prevented  from  picking  the  lip.  The  infant's  sleeves  may  be  pinned 
to  the  diaper  at  the  elbow.  With  older  children,  a  pasteboard  tube 
may  be  slipped  over  the  arm  from  the  wrist  to  the  axilla ;  this  will  pre- 
vent the  elbow  from  bending.     The  child's  arms  should  not  be  bound 


CLEFTS  OF  LIP  AND  ALVEOLAR  PROCESS.  241 

to  the  side  with  tight  wrapping  as  it  interferes  with  the  respiration 
and  the  natural  voluntary  movements.  Infants  should  be  given  plenty 
of  fresh  air,  and  in  good  weather  their  daily  outings  should  be  resumed 
a  day  or  two  after  operation. 

The  superficial  sutures  may  be  removed  on  the  fifth  or  sixth  day, 
but  the  lip  should  not  be  turned  back  to  remove  the  deep  stay  sutures 
for  ten  days  or  two  weeks ;  the  wire  in  the  alveolus  may  remain  much 
longer.     The  lead  or  silver  plates  are  removed  after  ten  days. 

RESULTS. 

We  have  never  seen  a  complete  failure  of  a  harelip  operation,  al- 
though they  have  occasionally  been  infected.  This  is  more  apt  to  oc- 
cur where  the  stay  sutures  include  any  part  of  the  skin.  The  resulting 
abscesses  discharge  spontaneously.  Gilmer  has  recently  told  us  of  a 
case  in  which  the  lip  failed  to  unite  purely  on  account  of  inanition,  the 
child's  temperature  remaining  below  95°  F.  for  several  days  after  op- 
eration. Slight  defects  are  apt  to  result  after  operation,  especially 
when  it  is  done  in  very  early  infancy.  If  the  defect  is  a  notch  at  the 
lip  border,  it  may  be  corrected  by  a  Rose  operation  at  the  time  the 
palate  is  repaired. 


CHAPTER  XVIII. 

OBTURATORS,  ARTIFICIAL  VELA,  AND  SPEECH 
TRAINING. 

In  order  to  treat  intelligently  a  cleft  of  the  velum,  either  by  opera- 
tion or  by  the  construction  of  an  obturator,  it  is  necessary  to  have  at 
least  a  general  idea  of  the  physiological  action  of  the  muscles  con- 
cerned, both  in  the  normal  and  in  the  cleft  palate. 

PHYSIOLOGICAL  ACTION  OF  THE  MUSCLE 
CONCERNED. 

The  velum  is  a  flap  valve  which,  when  raised  by  the  levator  palati 
muscles,  helps  to  completely  or  partially  close  the  nasal  from  the  oral 
pharynx  in  order  that  the  sounds  emanating  from  the  larynx  may  be 
modified  in  the  mouth  by  the  lips,  cheeks,  tongue,  teeth,  etc.,  (Fig.  207). 
A  very  few  sounds  known  as  nasals,  such  as  m,  n,  and  ng,  do  not  re- 
quire the  closure  of  the  nasopharynx  (Fig.  208).^ 

This  closure  of  the  nasopharynx,  which  also  occurs  during  degluti- 
tion, is  not  accomplished  entirely  by  the  velum,  but  partly  by  the  pos- 
terior pharyngeal  wall  coming  forward  to  meet  the  velum  in  the  form 
of  a  definite  protrusion,  known  as  Passavant's  cushion,  which  was  first 
described  by  Passavant  in  1868.  This  protrusion  is  due  to  the  con- 
traction of  the  upper  part  of  the  superior  constrictor  muscle  of  the 
pharynx,  that  part  which  arises  from  the  pterygoid  process,  and  is 
called  the  pterygopharyngeus.  Rose  has  denied  that  the  so-called 
"Passavant's  cushion"  is  due  to  the  action  of  the  superior  constrictor 
of  the  pharynx.  Dr.  Warnekros  points  out  that,  "such  notable  anato- 
mists as  Tourtual,  Luschka,  and  Zuckerkandl ;  such  physiologists  as 
Hermann,  Landois,  and  Munk  ;  such  singers  and  laryngologists  as  Volto- 
lini,  Zaifal,  Kingsley,  Frankel,  Wendt,  and  Myer  have  in  the  past  tested 
Passavant's  observation  very  exhaustively  and  have  recognized  it  as 
being  thoroughly  correct."  We  have  seen  cases  where  the  action  was 
very  plainly  visiljle.  In  Fig.  207,  Kingsley  illustrates  the  pad  help- 
ing to  close  the  nasopharynx,  while  in  Fig.  208  the  passage  is  shown 
to  be  open.  The  lower  part  of  the  superior  constrictor  muscle  of  the 
pharynx  (Fig.  209)  also  takes  part  in  narrowing  the  cavity  of  the  oral 
pharynx.     In  Fig.  20!)  by  K.  Warnekros,  a  shows  the     outline  of  this 

1  For  a  clearly  Illustrated  description  of  the  mechanism  of  speech,  see  Kings- 
ley's  Oral  Deformities. 

242 


OBTURATORS  AND  SPEECH  TRAINING. 


243 


part  of  the  constrictor  when  at  rest,  while  the  dotted  line  d  shows 
the  outline  of  the  muscle  during  contraction.  When  it  is  remembered 
that  the  palatopharyngei  and  the  palatoglossi  muscles  lie  within  the 
circle  of  this  muscle,  it  will  be  understood  how  it  is  that  the  contrac- 


Fig.  207.  Position  of  the  velum  and  Passevant's  cusliion  in  malting  the  sounds 
ah.  Tie  velum  and  cushion  close  the  opening  also  in  making  the  sounds  oo,  o,  a,  e,  u, 
i,  b,  p,  t,  d,  Ic,  g,  f,  V,  s,  z,  sh,  zli,  ih,  ch,  j,  I,  and  r. — After  Klngsley. 


Fig.  208.  Position  of  the  velum  in  making  the  sound  m.  Tlie  opening  into  the 
nasopharynx  also  remains  open  in  making  the  sounds  n,  ng.— After  Kingsley. 

tion  of  this  part  of  the  superior  constrictor  can  narrow  the  width  of  a 
cleft  in  the  velum  during  the  effort  of  speaking. 

The  tensor  palati  muscles,  as  their  name  implies,  by  their  action 
render  the  velum  tense,  but  in  the  presence  of  a  cleft  their  contraction 
causes  the  cleft  to  become  wider.  During  normal  nasal  respiration  the 
velum  is  held  against  the  pharyngeal  part  of  the  tongue  mainly  by  the 
action  of  the  palatoglossi  muscles. 


244 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


OBTURATORS  AND  ARTIFICIAL  VELA. 

From  this  meager  description  it  must  be  clear  that  operations  for 
the  correction  of  velum  clefts  must  aim  at  producing  a  velum  that  is 
long  enough  to  do  its  share  in  closing  the  nasopharynx ;  that  in  doing 
this  the  velum  must  be  left  sufficiently  pliable  to  move  freely  in  re- 
sponse to  its  various  muscles ;  and  that  these  muscles  must  not  be  crip- 
pled or  their  nerve  supply  cut.  It  can  also  be  understood  how  an  in- 
adequate velum  can  be  supplemented  by  an  obturator  that  closes  the 


9 


Fig.   209. 


IOm-> 


-    1 


Pig.   210. 

Fig.   209.      Diagram    illustrating    the    contraction    of    the    superior    pharyngeal    con- 
strictor   in  the   formation    of   Passavant's   cushion. — After   Warnel<ros. 
Fig.   210.      Obturator   for    a   cleft   palate. — After   Warnekros. 

cleft  and  partially  fills  the  space  behind  a  short  velum.  For  such  an 
artificial  velum  or  obturator  to  be  effective,  it  is  not  necessary  that  it 
fill  the  entire  passage  between  the  nasal  and  the  oral  pharynx.  It  must 
occlude  the  space  that  is  still  left  when  the  contraction  of  the  superior 
constrictor  muscles  forms  Passavant's  cushion  and  constricts  the  trans- 
verse diameter  of  the  pharynx  and  approximates  the  borders  of  the 
velum  cleft. 

Fig.  210  shows  an  obturator  constructed  by  Warnekros  for  a  pa- 
tient with  a  cleft.     Such  obturators  are  usually  made  of  vulcanite, 


OBTURATORS  AND  SPEECH  TRAINING. 


245 


but  the  part  filling  the  velum  may  be  of  flexible  rubber.  Once  par- 
tially occlude  the  nasopharynx,  and  the  diligent  patient,  by  efforts  at 
correct  speech,  will  develop  the  actions  of  the  muscles  to  the  extent 
that  later  a  smaller  obturator  is  sufficient.  Fig.  211  shows  the  obtu- 
rator that  was  worn  by  this  same  patient  subsequently. 

Fig.  212,  also  from  Warnekros,  shows  an  obturator  constructed  to 
compensate  for  a  short  velum  after  operation.  If  there  are  teeth  pres- 
ent, such  obturators  may  be  constructed  to  also  occlude  a  cleft  in  the 
hard  palate,  but  if  all  the  teeth  are  absent,  the  presence  of  an  anterior 


Fig.   211. 


Fig.   211.      Obturator  tliat  replaced  the  obturator  shown  in  the  preceding  figure  after 
the  palate   and  pharyngeal  muscles   had  been  trained. — After  Warnekros. 

Fig.   212.      Obturator    made   to   supplement   a   short   velum. — After   Warnekros. 

cleft  renders  the  problem  much  more  difficult.     It  has  been  our  obser- 
vation that  under  these  circumstances  obturators  are  of  little  benefit. 


"CLEFT  PALATE" SPEECH. 

When  a  person  has  learned  to  speak  with  a  cleft  in  the  velum,  even 
after  the  most  perfect  operation,  there  will  remain  the  stigma  of  the 
■'cleft  palate"  speech,  which  is  due  to  tiie  escape  of  air  through  the 
nasopharynx  during  the  effort  at  producing  sounds  that  require  its 
closure.  This  is  due  to  two  causes :  The  cleft  velum  is  shorter  than 
the  normal  velum,  and  this  defect  is  rarely  remedied  by  operation  ; 
further,  the  patient  who  has  learned  to  speak  with  a  cleft  velum  must 


246  SURGERY  OF  THE  MOUTH  AND  JAWS. 

be  reeducated  to  the  proper  use  of  the  newly  constructed  one.  In 
some  cases  in  the  presence  of  a  cleft,  by  diligent  effort,  the  patient  will 
develop  the  use  of  the  superior  constrictor  muscle  to  an  ultra  normal 
degree.  Such  persons  will  give  the  best  postoperative  results,  both 
on  account  of  the  muscular  control  that  has  been  acquired  and  because 
the  same  determination  that  produced  this  control  will  be  helpful  in 
mastering  the  use  of  the  new  palate.     This  also  applies  to  obturators. 

Older  children  who  have  cleft  palates  are  often  found  to  be  back- 
ward mentally,  simply  because  they  are  ashamed  to  ask  questions  on  ac- 
count of  the  difficulty  of  speech,  and  because  they  have  not  the  same 
incentive  to  study  as  children  who  are  corrected  and  chided  for  their 
mistakes  in  recitations  on  account  of  their  teachers  not  being  able  to 
understand  them.  Several  schemes  of  postoperative  speech  training 
have  been  devised,  among  which  is  the  teaching  of  a  foreign  language 
that  has  not  been  previously  attempted  by  the  pupil.  A  simple  and 
rather  efifective  plan,  devised  by  Bigelow,  is  given  below,  and  is  the 
one  we  employ. 

SPEECH  TRAINING. 

Begin  with  the  only  consonant  which  a  patient  can  usually  best 
articulate,  namely  t  in  tar,  and  gradually  lead  to  the  rest,  constantly 
referring  to  the  acquired  f  as  a  point  of  departure.  The  great  difficulty 
in  pronouncing  correctly  with  a  cleft  palate  is  in  distinguishing  the 
nasals  from  the  mutes :  thus  p-b  from  m;  pap  or  bab  from  mam;  t-d 
from  n;  fat  from  nan;  k-g  (hard)  from  ng.  Tar  is  well  pronounced 
by  most  beginners  with  an  obturator.  When  the  beginner  can  pro- 
nounce stark  and  car,  he  has  the  key  to  most  of  what  follows  here. 
The  above  words  should  be  practiced  carefully  and  should  be  spoken 
loudly,  or,  as  the  elocutionists  say,  "exploded." 

1.  tar  artar   kar        ark  gar  kar 

2.  kar  arkar  arkgar  kgar      gar 

3.  kar  arkar  arkdar  kdar      dar 

4.  kar  arkar  arkpar  kpar      par 

5.  kar  arkar  arkbar  kbar      bar 

6.  kar  arkar  arklar    klar       lar 

7.  kar  arkar  arksar   ksar      sar 

Practice  all  the  above  with  the  following  vowels : 

8.  0  as  in  coke. 

Thus,  instead  of  kar,  akar,  ko-oko-oklo-klo-lo. 

9.  along  as  in  cake. 

10.  i  as  in  kite. 

11.  e  as  in  keep. 


OBTURATORS  AND  SPEECH  TRAINING.  247 

12.  u  as  in  suit. 

13.  kar  crkar  arngar  arkar  arngar  kar  ngar  bar  mar 

14.  tar  artar    arnar    artar    arnar    tar   nar    dar  mar 

15.  par  arpar   aniiar   arpar  armor   par  mar   sar  rar 
Practice  reading  loudly  from  a  book. 

A  patient,  painstaking  teacher  and  a  docile,  earnest  pupil  are  two 
factors  that  go  a  long  way  toward  success.  If,  after  a  thorough  trial  of 
this  training,  a  good  enunciation  is  not  acquired,  the  surgeon  may 
recommend  an  auxiliary  obturator  (Fig.  211)." 

POSTPHARYNGEAL  INJECTION  OF  PARAFFIN. 

This  has  been  used  to  supplement  a  short  velum.  Warnekros  ob- 
jects to  this  for  fear  that  it  would  interfere  with  the  action  of  the 
superior  constrictor  muscle,  while  from  observation  of  results  of  par- 
affin injections  that  have  come  to  our  notice,  we  have  refrained  from 
using  them. 

OBTURATORS  VERSUS  OPERATION. 

The  once  rather  spirited  dispute  between  those  who  favored  the  use 
of  obturators  versus  those  who  favored  operative  treatment  of  clefts  is 
all  but  settled  in  favor  of  the  latter.  If  any  further  argument  were 
needed  against  the  routine  treatment  by  means  of  obturators,  it  could  be 
found  in  the  fact  that  Gutzmann,  with  his  exceptional  opportunities  of 
observation  on  this  point,  has  come  to  the  conclusion  that  the  operative 
results  are  the  best. 

Only  in  exceptional  cases  is  the  subject  of  operative  risk  to  be  taken 
into  consideration  in  making  a  choice,  although  there  is  a  certain  risk 
in  any  operation,  and  the  death  rate  from  cleft  palate  operation  per  sc  is 
almost  nil;  and  an  open  palate  must  more  or  less  predispose  to  in- 
fections of  the  respiratory  tract  and  middle  ear.  It  is  to  be  hoped  that 
the  knowledge  of  the  immense  advantage  of  the  early  operation  will 
soon  become  so  disseminated  that  before  many  years  a  child  or  an 
adult  with  an  unoperated  cleft  will  be  as  rare  as  are  cases  of  large 
ovarian  cysts  today. 


2  We  frequently  recommend  that  these  patients  attend  classes  In   a  deaf-and- 
dumb  school,  or  obtain  the  services  of  a  teacher  from  such  a  school. 


CHAPTER  XIX. 

REPAIR  OF  ACQUIRED  DEFECTS  IN  THE  HARD  AND  SOFT 
'^  TISSUES  OF  THE  FACE. 

Defects  in  the  soft  tissues  of  the  face  and  mouth  are  repaired  by  the 
sliding,  or  transplantation,  of  flaps  of  mucus-  or  skin-covered  tissue, 
which  are  grafted  into  a  new  position.  These  flaps  may  be  made  from 
neighboring  tissue,  from  tissue  transplanted  from  some  distant  site,  or 
even  with  tissue  obtained  from  some  other  person.  The  latter  proced- 
ure is  almost  entirely  confined  to  the  transplantation  of  pieces  of  skin  or 
of  the  superficial  layers  of  the  skin. 

In  certain  instances  the  defect  is  hidden  by  the  use  of  some  artificial 
structure  that  is  made  to  resemble  the  missing  part  such  as  a  wax 
or  celluloid  ear  or  nose.  This  art  has  been  developed  to  a  very  high 
degree  by  Cruise,  Hastings,  and  Wood,  who  use  metallic  masks  to 
cover  the  missing  parts,  painted  to  resemble  the  lost  surface  tissues. 
When  the  defect  is  of  the  bony  structure,  it  may  be  repaired  by  the 
transplantation  or  sliding  of  bone  or  cartilage  grafts,  or  by  the  inter- 
position of  some  artificial  structure  such  as  the  Marten's  splint  (p.  464) 
and  the  modification  (p.  123).  Where  the  defect  involves  both  the  bone 
and  soft  tissue  the  bone  gap  may  be  compensated  by  an  artificial  inlay 
(Marten's  splint)  and  the  soft  tissue  repaired  by  flaps  planted  over  this, 
or  the  soft  tissue  repair  may  be  made  first  with  subsequent  implantation 
of  bone  or  cartilage.  The  bone  or  cartilage  may  be  part  of  the  soft 
tissue  flap  and  both  structures  repaired  at  once. 

VARIETIES  OF  GRAFTS. 

1.  Soft  Tissue  Grafts. — Skin  or  mucous  membrane  and  super- 
ficial fascia  may  be  employed  in  the  form  of  sliding  or  pedicled  flaps, 
or  the  skin  alone  may  be  transplanted  as  free  grafts  as  by  the  Thiersch 
and  Wolfe  methods. 

Sliding  flaps  are  formed  by  undermining  the  tissues  in  the  neigh- 
borhood of  the  defect,  mobilizing  them  so  that  they  can  be  brought 
together  to  cover  the  gap. 

A  pedicled  flap  is  made  by  cutting  from  the  sound  tissues  an  area  of 
suitable  size  and  shape  to  cover  the  defect,  turning  it  into  the  defect, 
leaving  a  portion  of  the  flap  attached  to  its  original  site  to  maintain 
its  blood  supply  until  healing  takes  place  in  tbe  new  situation. 

Fat  grafts  may  be  employed  advantageously  in  filling  depressions 

248 


REPAIR  OF  ACQUIRED  DEFECTS.  249 

in  the  soft  tissues  aboiit  the  face.  Transplanted  fat  from  the  patient's 
abdominal  wall  is  usually  employed. 

2.  Bone  may  be  transplanted  to  fill  defects  in  the  jaw  bones. 
Free  hone  transplants  are  usually  obtained   from  the  ribs  or  the 

tibia.  The  transplant  is  either  placed  directly  in  the  defect  (direct 
transplantation)  or  buried  in  the  neighboring-  soft  tissues  until  it 
gains  attachment,  and  later  moved  into  the  defect  by  a  sliding  opera- 
tion  (mediate  transplantation). 

Pediclcd  bone  transplants  may  be  obtained  from  the  neighboring 
portion  of  the  jaw  bone. 

3.  Cartilage  is  obtained  in  the  form  of  free  transplants  from 
the  6th,  7th,  and  8th  costal  cartilages  and  is  used  to  replace  lost  por- 
tions of  the  nasal  and  malar  bones,  and  the  maxilla  and  mandible. 

4.  Combined  Bone  and  Soft  Tissue  may  be  directly  trans- 
planted to  the  lower  jaw  region  from  the  clavicle  and  tissues  of  the 
neck.  Mediate  transplantations  of  rib  and  tibia  may  also  be  made, 
the  secondary  graft  comprising  also  the  soft  tissues  of  the  region  in 
which  the  bone  was  embedded. 

TRANSPLANTATION  OF  SKIN-  OR  MUCUS- 
COVERED  FLAPS. 

The  surgical  possibility  of  transplanting  skin-  or  mucus-bearing  flaps 
for  the  correction  of  tissue  defects  depends  upon  the  following  facts : 

The  skin  and  superficial  fascia  are  redundant  and  elastic.  The  nu- 
trition of  a  flap  can  be  maintained  through  a  relatively  small  pedicle, 
if  it  is  accompanied  by  a  layer  of  the  subcutaneous  fascia,  and  especially 
if  this  pedicle  contains  a  distinct  artery  and  vein.  A  flap  of  skin  from 
which  all  subcutaneous  tissue  is  removed,  and  which  is  not  connected 
by  a  pedicle,  is  known  as  a  Wolfe  graft.  Its  life  is  much  less  certain 
than  that  of  a  flap  that  retains  a  blood  supply,  but  it  has  this  advantage  : 
that  it  can  be  obtained  from  a  distant  site,  such  as  the  thigh.  Grafts 
made  of  thin  shavings  from  the  epidermis  are  used  to  cover  raw  sur- 
faces from  which  the  skin  is  missing.  These  are  known  as  Thiersch 
grafts.  After  a  flap  has  united  in  a  new  position  and  a  new  blood 
supply  is  obtained,  the  pedicle  can  be  cut  without  injury  to  its  nutrition. 
Skin  transplanted  into  the  mouth  is  a  practical  substitute  for  mucous 
membrane. 

Flap  grafts  may  be  undertaken  in  the  presence  of  mild  infection, 
but  to  have  any  chance  of  success,  free  transplants  should  only  be 
attempted  with  an  absolutely  clean  field. 

As  concerns  the  mechanical  repair,  it  matters  little  whether  a  de- 
fect is  the  result  of  the  excision  of  a  scar  or  tumor,  or  whether  it 
is  a  destructive  trauma.     In  the  following  an   attempt  will  be  made 


250  SURGERY  OF  THE  MOUTH  AND  JAWS. 

to  present  the  simplest  effective  methods  of  repairing  the  various  de- 
fects that  may  occur  from  disease,  accident,  or  surgical  operation  about 
the  Hp,  cheeks,  neck,  and  jaws. 

If  the  margins  of  the  defect  are  infected,  the  acute  inflammation 
should  be  allowed  to  subside  and  a  healthy  granulating  surface  estab- 
lished before  any  repair  is  attempted,  but  it  is  not  necessary  that  the 
edges  of  the  wound  go  on  to  scar  formation  and  epithelialization. 

Both  in  civil  and  military  practice  when  it  is  compatible  with  safety 
the  quicker  the  wound  is  repaired  the  better,  and  the  difference  in 
time  between  repairing  in  the  presence  of  healthy  granulations  and 
waiting  till  all  surfaces  are  epithelialized  is  usually  a  matter  of  months 
and  possibly  years. 

Before  undertaking  to  make  the  repair,  all  dead  bone  should  be 
removed,  the  remaining  exposed  bone  should  be  covered  with  healthy 
granulations  and  there  should  be  no  pus  pockets,  discharging  or  blind. 
When  this  condition  has  been  obtained,  which  with  proper  treatment 
can  usually  be  effected  within  from  three  weeks  to  three  months  in 
civil  life,  it  is  good  practice  to  make  the  repair  by  flap  grafts.  In 
the  war  zones,  the  prevalence  and  virulence  of  bacteria  have  led  to 
the  dictum  that  granulating  surfaces  should  not  be  disturbed  until  they 
have  been  rendered  almost  sterile,  and  that  recent  scars  should  not 
be  disturbed  for  90  days  after  the  wound  has  healed. 

The  writer  would  not  undertake  to  criticize  this  practice  which  was 
forced  on  the  surgeons  by  the  bad  results  that  followed  other  practices, 
but  would  still  strongly  urge  the  advantages  of  early  repair  and  that 
those  practicing  in  the  war  zone  take  such  means  as  have  been  de- 
veloped to  early  render  their  mouth  wounds  free  from  virulent  bacteria 
and  then  make  their  repairs  as  early  as  possible  by  bold  flap  opera- 
tions rather  than  meager  timid  tissue  sliding. 

If  the  defect  be  the  result  of  the  removal  of  a  tumor,  or  the  wound 
edges  have  wholly  or  partially  scarred,  one  of  the  first  essentials  in 
the  repair  is  the  removal  of  all  of  the  original  diseased  tissue,  and 
except  in  extraordinary  cases,  this  refers  also  to  scar  tissue. 

If  the  tumor  has  been  removed  by  the  use  of  the  cautery  iron,  all 
slough  should  be  allowed  to  separate  and  a  clear  granulating  surface 
be  present.  If  a  low  heat  cautery  is  used,  the  separation  of  sloughs 
is  often  very  slow.  If  bone  has  been  Ijurnt  the  separation  of  the 
shell  of  dead  bone  is  even  more  tedious  and  iwn  and  a  half  to  three 
months  may  be  required  before  it  can  be  cleanly  removed  without 
damage  to  the  underlying  live  bone.  If  the  defect  is  the  result  of 
syphilis,  the  patient  should  have  been  thoroughl_\-  treated  before  an 
operation  is  undertaken.     It  was  an  old  rule  that  operative  correction 


REPAIR  OF  ACQUIRED  DEFECTS. 


251 


of  defects  with  syphilitic  lesions  should  not  be  attempted  until  months 
after  all  active  manifestations  had  disappeared. 

These  are  in  many  cases  elective  operations,  and  such  should  be 
performed  only  when  the  general  condition  of  the  patient  is  the  best 
possible. 

Flaps  should  be  made  ample  in  size.  When  possible,  they  should 
be  so  planned  that  they  may  be  enlarged  should  it  be  found  necessary. 
While  it  is  certainly  true  that  face  flaps  wall  stand  a  great  amount  of 
tension  without  sloughing,  it  is  equally  true  that  the  result  is  better, 
as  regards  both  the  comfort,  appearance  and  function,  when  the  tissues 
are  not  overstretched.  The  blood  supply  of  the  face  tissues  is  particu- 
larly good,  but  nutrition  should  always  be  considered  in  planning  flaps. 


Branch  of  occipitofrontalis  in. 

Branches  of  orbicularis 
palpebrarum  m. 

Zygomatic  muscles. 

Parotid  duct. 

Branches  of  buccinator  muscle. 

Parotid  gland. 
Masseter  muscle. 

Inframandibular  branches  of 
depressor  muscles. 


Fig.   213.      The  facial  branches  of  the  seventh  nerve  and  of  the  parotid  duct. 

Preservation  of  the  Epithelial  Lining  of  the  Mouth. — In  repair- 
ing defects  of  the  lips  and  cheeks,  the  oral  as  well  as  the  external 
aspect  is  to  be  considered,  for,  if  an  extensive  raw  surface  is  left 
within  the   vestibule,   subsequent  contraction  will  modify  the  result. 

Preservation  of  the  Motor  Nerves. — When  flaps  are  liberated  by 
deep  incisions,  some  nerves  will  be  sacrificed,  but  the  motor  supply  of 
the  orbicularis  palpebrarum  muscle  should  not  be  endangered.  If 
the  external  incision  does  not  extend  behind  a  line  running  from  the 
lobe  of  the  ear  to  the  middle  of  the  lower  border  of  the  orbit,  the 
ability  to  close  the  eye  will  not  be  menaced  (Fig.  213).     ^^l^en  there 


253  SURGERY  OF  THE  MOUTH  AND  JAWS. 

has  been  an  extensive  reconstruction,  the  nerve  supply  of  the  bucci- 
nator, orbicularis  oris,  etc.,  of  that  side  is  relatively  not  so  important, 
for  the  newly  made  cheek  and  lip  remain  stiff  v^ith  scar  tissue  and 
will  not  be  drawn  aside  by  the  opposite  buccinator  as  in  Bell's  palsy. 
The  nerve  supply  of  the  upper  part  of  the  orbicularis  oris  and  the 
muscles  that  raise  the  lips  and  control  the  nostrils  runs  deep  to  the 
zygomatic  and  levator  anguli  oris  muscles,  so  that  a  superficial  flap 
can  be  raised  from  the  area  between  the  orbit  and  mouth  without 
cutting  the  motor  supply  of  these  muscles.  In  sliding  flaps  made 
from  the  face  tissues,  the  most  important  thing  is  free  undermining. 
When  done  in  the  proper  plane,  this  cuts  no  motor  nerves  and  few 
vessels,  and  leaves  no  visible  scar.  External  incisions  for  releasing 
face  flaps  should  be  made  only  when  undermining  by  itself  will  not 
suffice.  But  when  tissues  are  going  to  be  very  tense  it  is  better  to 
interpose  a  flap  brought  from  some  neighboring  area.  For  cutaneous 
flaps  the  undermining  should  be  done  superficially  to  the  muscles  of 
expression.  On  the  side  of  the  face  the  masseter,  the  temporal  fascia, 
or  the  zygoma  should  not  be  laid  bare,  for,  after  leaving  the  parotid 
gland,  the  nerves  lie  in  contact  with  these  structures. 

Cheek  Flaps. — The  first  procedure  in  freeing  a  flap  which  in- 
cludes the  full  thickness  of  the  cheek  is  to  cut  the  mucuous  membrane 
and  buccinator  from  the  bone.  Posteriorly  they  are  to  be  cut  along  the 
inner  surface  of  the  anterior  border  of  the  masseter  muscle,  which  will 
not  cut  the  motor  supply  of  the  buccinator.  In  raising  the  flap  from 
the  masseter  muscle,  it  is  to  be  remembered  that  the  parotid  duct  and 
motor  nerves  lie  in  immediate  contact  with  its  external  surface  and 
should  be  either  lifted  from  the  muscle  or  left  in  place,  as  the  case 
may  be,  without  being  cut. 

Forehead  Flaps. — For  filling  large  defects  in  the  cheek,  the 
transplantation  of  a  flap  supplied  by  the  anterior  temporal  artery,  as 
described  by  Horsley  (Fig.  214),  is  valuable.  The  flap  is  cut  from 
the  anterior  temporal  region  of  a  size  and  shape  to  fill  the  defect,  and 
the  anterior  temporal  artery  with  its  veins  and  surrounding  connec- 
tive tissue  is  left  attached  to  the  flap  and  dissected  out  of  its  bed  as 
far  as  necessary.  The  new  bed  for  the  vessels  is  made  by  an  incision 
which  merely  goes  through  the  skin  so  as  not  to  cut  the  branches 
of  the  facial  nerve.  This  incision  leads  from  the  point  of  exit  of  the 
vessels  to  the  edge  of  the  defect.  The  skin  is  undermined  on  each  side 
so  as  to  cover  the  artery  without  tension.  The  vessels  are  placed  in 
the  incision  and  covered  by  the  skin  suture.  The  wound  from  which 
the  flap  was  taken  is  closed  by  skin  graft  if  necessary. 

In  doing  this  operation,  the  procedure  may  be  modified  to  turn 
the  skin  into  tlie  buccal  cavity  as  follows  :     The  flap  is  liberated  from 


REPAIR  OF  ACQUIRED  DEFECTS. 


253 


the  forehead  as  described  and  the  edges  of  the  defect  prepared.  When 
the  defect  is  through  the  full  thickness  of  the  cheeks  and  has  been 
allowed  to  scar  for  some  time,  after  the  scar  is  removed  it  will  be 
found  that  the  defect  on  the  mucous  surface  may  be  much  larger 
than  the  cutaneous.  If  this  is  the  case,  the  flap  is  fitted  into  the  de- 
fect, skin  surface  towards  the  mouth,  and  sutured  along  its  upper 
anterior  and  lower  anterior  borders.  The  exposed  raw  surface  of 
the  flap  is  covered  with  Thiersch  grafts.  Two  weeks  later  after  the 
flap  has  healed  in  place,  after  testing  the  acquired  blood  supply  by 
gently  pinching  the  pedicle,  the  latter  is  cut  and  the  posterior  border 
of  the  flap  is  tucked  under  the  posterior  edge  of  the  defect  and  sutured 
in  place.  This  method  restores  the  epithelial  lining  of  the  cheek  as 
well  as  the  outer  covering  which,  if  the  patient  is  expected  to  open 
his  mouth,  is  of  greater  importance.     (See  Figs.  215,  210,  and  217.) 


/  v^- 


''"^^■;^. 


■i^tr-       ,r         Trj-^<=- 


Fig.    214.      Transplantation    of   forehead    flap    with    anterior   temporal    artery,    to    fill 
defect  of  cheek. — After  Horsley. 


In  planning  the  flap,  care  should  be  taken  to  include  no  hair-bear- 
ing area,  as  the  latter  will  continue  to  grow  after  transplantation  into 
the  mouth.  The  forehead  flap  with  its  base  at  the  angular  artery  is 
sometimes  used  in  repairing  a  nasal  defect. 

Flaps  from  the  Neck. — In  obtaining  long  flaps  from  the  neck, 
the  platysma  myoides  muscle  should  be  included.  The  jugular  vein, 
the  cutaneous  branches  of  the  superficial  cervical  nerve  plexus,  and  the 
sternomastoid  muscle  lie  just  beneath  the  platysma  muscle  and  are 
to  be  used  as  guides,  as  in  children  and  delicate  women  the  fibers  of 
the  muscle  may  not  be  visible.     If  the  neck  defect  is  to  be  closed  by 


254 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Fig.  215.  Shows  defect  with  skin  borders  drawn  by  scar  contraction.  The  first 
procedure  is  to  make  the  two  incisions  a-a,  undermining  freely  tlie  skin  borders  of  the 
defect   above    in   front  and   below. 


Fig.   216 


Fig.    217. 


Fig.  216.  The  flap  liberated  from  the  forehead  is  then  tucked  into  the  defect 
through  the  incisions  a,  a  (Fig.  215),  the  skin  surface  towards  the  mouth.  The  skin  of 
the  cheek  is  sutured  to  the  raw  surface  of  the  flap,  and  the  remaining  raw  surface  im- 
mediately grafted. 

Fig.  217.  After  the  flap  has  acquired  a  blood  supply  from  the  cheek,  it  is  cut  along 
the  dotted  line  /;,  b  (Fig  216)  ;  and  after  undermining  the  skin  of  the  posterior  border 
of  the  defect,  the  posterior  edge  of  the  cheek  flap  is  tucked  under  it,  and  the  remaining 
part     of  the  forehead   flap   is  replaced   into  the   forehead   defect, 


REPAIR  OF  ACQUIRED  DEFECTS. 


255 


drawing  over  the  neighboring  skin,  Ihese  sensory  nerves  are  to  be 
left  in  place,  but  if  the  space  is  to  be  covered  with  Thiersch  grafts,  the 
exposed  nerve  had  best  be  removed.  In  a  well-nourished  adult  a  flap  5 
centimeters  wide,  with  its  base  at  the  lower  jaw,  can  be  made  to  in- 
clude the  tissue  down  to  6  centimeters  below  the  clavicle.  After 
undermining  the  platysma  on  both  sides  of  the  defect,  unless  there 
is  too  much  fat,  the  remaining  skin  can  be  brought  together  with 
sutures  so  as  to  leave  only  a  linear  scar  (Fig.  180).  The  scar  may 
be  thick  and  corded,  but  later,  after  the  tissues  have  become  adjusted, 
it  may  be  excised,  leaving  only  a  smooth  line  scar.  It  is  usually  well 
to  make  a  counter-opening  on  each  side  at  the  bottom  of  the  under- 
mining pocket,  which  will  serve  for  relaxation  and  drainage.  If  it  is 
found  difficult  to  approximate  the  edges  of  the  defect,  these  drainage 
wounds  may  be  extended  by  linear  incisions  parallel  to  the  line  of 
suturing.     As   these  wounds  gap,   the   tension  will  be   released ;  they 


Pig.  218.  Neck  flap,  circulation  of  which  was  doubtful,  sutured  in  place.  Two 
days  after  making  the  flap,  it  shows  a  slough  at  Its  lower  end. 

will  later  close  without  suturing.  If  the  flap  is  of  such  size  that  the 
resulting  defect  cannot  be  obliterated  by  suturing  its  borders,  or  by 
sliding  other  flaps  from  the  neighborhood,  then  the  raw  surface  should 
be  immediately  grafted  according  to  the  method  of  Thiersch. 

A  plan  we  have  used  consists  in  raising  the  flap,  controlling  the 
bleeding  by  twisting  the  vessels,  and  then  covering  the  raw  surface 
with  Thiersch  grafts.  The  grafted  area  is  covered  with  several  thick- 
nesses of  silver  leaf  and  then  with  two  thicknesses  of  gauze,  wet  with 
a  10  per  cent  colloidal  silver  solution.  Next,  the  flap  is  sutured  by  its 
edges  to  the  edges  of  the  defect,  and  two  days  later  the  flap  is  freed 
and  transferred  to  the  desired  position.  The  rationale  of  this  pro- 
cedure is  that  the  silver  leaf  and  colloidal  silver  are  antiseptic  and  non- 
irritating.  The  silver  leaf  prevents  the  gauze  from  sticking  and 
displacing  the  grafts,  and  the  gauze  prevents  the  under  surface  of  the 
flap  from  becoming  coated  with  silver.     Leaving  the  flap  in  its  old 


256 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


position  should  assure  its  vitality  before  it  is  transferred,  and  suturing 
it  there  prevents  it  from  shrinking  and  makes  it  an  excellent  mechanical 
protection  to  the  grafts  in  a  region  where  it  is  ordinarily  difficult  to 
prevent  friction  of  the  dressings  from  displacing  them. 

Flaps  from  the  Shoulder  and  Chest. — In  turning  very  large 
flaps  from  the  shoulders,  chest,  or  back  for  the  repair  of  the  neck  and 
lower  part  of  the  face  after  extensive  burns,  the  desired  flap  may  be 
outlined,  and  freed  by  beginning  the  dissection  at  its  lower  end.  If  at 
any  time  during  the  dissection  the  circulation  in  the  freed  parts  seems 
deficient,  it  is  better  to  graft  the  defect  and  replace  the  flap  as  de- 
scribed  above,   and   wait  two   days  before   completing  the   flap   and 


Fig.   219.     Scheme  for  incision  for  obliterating  a  defect   at  the  corner  of  the  mouth. 


putting  it  into  its  new  place.  The  sloughing  of  a  large  flap  is  such  a 
serious  disappointment  to  both  the  surgeon  and  the  patient  that  no 
unnecessary  hazard  should  be  taken.  The  flaps  should  be  transferred 
to  their  new  position  within  two  days  of  being  raised ;  otherwise  con- 
traction will  greatly  lessen  the  size  of  the  flap.  If  after  transplanta- 
tion, before  dressings  are  applied,  the  skin  appears  blue  and  turgid, 
some  means  of  controlling  this  must  be  employed. 

As  a  rule  a  flap  sloughs,  not  from  want  of  arterial  supply,  but 
from  tardiness  in  the  establishment  of  a  venous  return.  Such  a  flap 
should  be  scored  with  a  sharp  knife  until  it  becomes  pale.  Ordinarily 
the  blood  will  soon  clot  in  these  cuts  and  the  scoring  will  have  to 
be  repeated  at  intervals  until  the  venous  return  is  established.  If, 
immcfliately   after   scoring,  a   pad  mcjistened   in   a   one  per  cent  solu- 


REPAIR  OF  ACQUIRED  DEFECTS. 


257 


tion  of  sodium  citrate  is  applied  and  renewed  before  it  dries,  the  bleed- 
ing will  be  k'ept  up  very  much  longer.  Flaps  carefully  watched  and 
treated  in  this  way  will  seldom  slough. 

Blood  Supply  o£  a  Transplanted  Flap. — Before  cutting  the  base 
of  a  transplanted  flap,  it  should  be  gently  pinched  with  forceps,  and 
at  the  same  time  its  color  observed.  In  this  way  the  surgeon  can 
satisfy  himself  that  the  circulation  through  its  new  attachment  is  suffi- 
cient. Transplanted  flaps  should  be  sutured  with  through-and-through 
interrupted  sutures  of  fine  silkworm  gut  or  silver  wire,  and  especially 
in  the  case  of  long  flaps,  the  sutures  should  be  drawn  but  very  loosely. 
The  circulation  in  these  new  flaps  is  poor  at  best,  and  tight  sutures  may 
be  the  determining  cause  of  sloughing  along  the  line  where  union  was 
expected. 


Pig.   220. 


Fig.    221. 


Fig.  220.  Diagram  of  a  clieeli  defect  and  a  flap  from  tlie  neck.  Tbe  lower  end  of 
the  neck  flap  has  been  doubled  on  itself  so  as  to  be  covered  with  skin  on  both  surfaces. 

Pig.  221.  Shows  second  step  in  closing  cheek  defect.  The  part  of  the  flap  that  was 
shown  doubled  upon  itself  in  the  preceding  figure  has  been  sutured  by  its  free  borders, 
both  to  the  mucous  membrane  and  to  the  skin.  Nothing  further  can  be  done  until  the 
flap  obtains  sufficient  nourishment  from  its  new  attachment. 

CLOSURE  OF  DEFECTS  AT  THE  ANGLE  OF  THE 
MOUTH  AND  OF  THE  CHEEK. 

To  obtain  the  flaps,  the  mucous  membrane  and  buccinator  muscle 
are  to  be  detached  from  the  bone  at  the  upper  and  lower  fornices,  and 
the  cheek  undermined  up  to  the  opening  of  the  infraorbital  canal  and 
down  to  the  lower  border  of  the  mandible.  If  after  this  the  cheek 
defect  cannot  Se  closed  by  suturing  the  outer  part  of  the  edge   (a-b) 


258 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


to  (b-c),  the  incision  (a-d)  may  be  made  in  the  cheek  (Fig.  219). 
After  the  cheek  defect  is  obhterated,  the  lips  with  their  mucous  lin- 
ing may  be  drawn  into  proper  place  by  making  one  or  both  of  the 
transverse  incisions  illustrated.  (See  Fie.  '232.)  Particular  care 
should  be  taken  in  locating  the  corner  of  the  mouth.  If  the  incisions 
alorig  the  uppef  and  lower  lip  extend  beyond  the  mouth  slit  on  the 
unafifected  side,  that  corner  of  the  mouth  will  be  drawn  toward  the 


Fig.    222. 

Fig.  222.  Final  stage  in  closing  a  cheek  defect  by  a  neck  flap.  Having  determined 
by  pinching  the  pedicle  that  the  flap  is  obtaining  sufficient  nourishment  from  its  new 
attachment,  the  pedicle  is  cut  close  to  cheek  attachment.  The  upper  and  lower  borders 
of  the  cheek  wound  are  freshened,  as  in  the  upper  border  of  the  flap  where  it  was  bent 
on  itself.  These  are  sutured.  The  triangular  defect  in  the  upper  part  of  the  neck  is 
freshened,  and  the  pedicle  of  the  flap  is  fitted  into  it. 

Fig.  223.  The  Serre  operation  for  restoring  the  angle  of  the  mouth  after  it  has 
been  depressed  by  a  scar. 


median  line,  and  the  new  angle  of  the  other  side  will  have  to  be 
adjusted  accordingly.  In  this  way,  when  much  of  the  lip  is  miss- 
ing, a  smaller  symmetrically  placed  mouth  slit  will  result.  Without 
the  incision  (Fig.  219,  a-d),  this  operation  will  cut  only  the  mental 
branch  of  the  interior  dental,  and  possibly  the  infraorbital  nerve.  An 
external  drainage  through  a  stab  wound  at  the  lower  border  of  the  jaw 
is  desirable. 

For  more  extensive  defects  of  the  cheek,  Israel  proposed  using  a 
flap  turned  from  the  neck,  the  non-hairy  part  of  which  is  sutured  into 
the  defect  around  three  sides  of  its  border,  with  the  skin  surface  toward 
the  mouth.     Some  time  later,  when  the  flap  is  well  nourished  from 


REPAIR  OF  ACQUIRED  DEFECTS. 


259 


its  new  attachment,  the  flap  is  cut  at  its  base,  and  the  pedicle  of  the 
flap  is  turned'  into  the  defect,  skin  side  toward  the  face.  Another  ten 
days  or  two  wrecks  would  have  to  pass,  before  the  continuity  of  the 
two  halves  can  be  cut  and  final  repair  made.  We  have  never  tried 
this  for  the  reason  that  in  two  or  three  weeks  the  raw  surface  of  the 
pedicle  would  contract  and  would  be  difficult  to  manage.  If  the  cheek 
could  not  be  closed  by  simply  undermining  down  into  the  neck,  we 


Fig.  224.     Showing   result   of   the    Burow-Stewart   operation    for    restoration    of   the 
lip  and  chin. 


would  prefer  to  do  the  operation  shown  in  Figs.  220,  221,  and  232. 
This  can  be  completed  in  two  steps  and  does  not  use  a  raw  surface 
that  has  been  contracting  for  a  week  or  more,  as  does  Israel  in  his 
operation.  We  believe  that  the  Horsley  operation  (page  252)  or 
the  modification  also   described   is   superior  to   Israel's. 

Some  have  closed  a  defect  in  the  cheek  by  splitting  the  border  of 
the  tongue  and  suturing  the  raw  surface  into  the  defect.  Later  the 
remaining  part  of  the  tongue  is  cut  loose.     This  should  be  done  only 


260 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


in  young,  healthy  subjects,  for  any  anchoring  of  the  tongue  may  pre- 
dispose to  pneumonia. 

If  the  corner  of  the  mouth  is  ch-awn  down  (Fig.  233),  it  can  be 
restored  to  a  good  position  by  an  operation  that  bears  the  name  of 
Serre. 

The  two  incisions  around  the  mouth  are  made  so  that  the  dis- 
torted portion  of  the  Hps  can  be  freed  and  laid  on  the  cheek  in  the 


A 

0 

'^^^m 

m 

^i^^^M 

^, 

4 

IMI^^ 

f  " 

^ 

swp' 

1 

IH^- 

IhHLc.^ 

,4 

■■■-  i 

m 

—..■'".jimmu.-jm:^ 

_c^-^^ 

tion. 


Fig.    s^r,.      Showing  ability  to  elevate  the  upper   lip  after   the  liurow-Stewart  opera- 


desired  position.  This  will  give  an  index  to  the  position  and  length 
of  the  incision  in  the  cheek.  The  flap  (a)  is  then  drawn  down  to 
occupy  the  place  from  which  the  corner  of  the  mouth  was  removed, 
and  the  latter  is  sutured  into  the  defect  left  in  the  cheek. 

RESTORATION  OF  THE  LOWER  LIP. 

The  upper  lip  or  the  lower  lip  and  chin  can  be  restored  with  mucous 
lining  by  the  operation  described  by  J.  Clark  Stewart.     According  to 


REPAIR  OF  ACQUIRED  DEFECTS.  261 

Esmarch  and  Kowalzig,  the  idea  of  removing  a  triangular  flap  from 
the  cheek  belongs  to  Burow,  and  in  presenting  it  Esmarch  and  Kowal- 
zig suggest  the  advantageous  possibility  of  using  the  mucous  lining  of 
the  discarded  areas  as  covering  for  the  free  border  of  the  new  lip  (Figs. 
224,  225,  226,  and  227). 

The  whole,  or  nearly  all,  of  the  lower  lip  and  the  covering  of  the 
chin  having  been  removed,  the  cheek  is  freed  from  its  attachment 
by  an  incision  along  the  lower  border  of  the  bone.  In  an  operation  for 
carcinoma,  this  incision  would  have  probably  been  made  previously  in 
removing  the  glands  of  the  neck.  Next,  an  incision  (a-b)  (Fig.  227) 
is  outlined  with  the  point  of  the  knife,  its  length  corresponding  to  less 
than  half  of  the  width  of  the  gap  in  the  lip.     If  less  than  three  fifths 


A  B 

Pig.  226.  Showing  condition  four  weeks  after  removal,  with  a  saw  and  cautery,  of 
lower  half  of  right  cheek  and  lip,  the  right  half  of  the  body  of  the  mandible,  and  the  right 
half  of  the  floor  of  the  mouth  with  the  skin  and  nodes  in  the  right  submaxillary  region. 
Note  the  enlarged  tongue  resting  on  the  neck.  B  shows  repair  by  flap  from  side  of  neck 
down  six  weeks  after  first  operation.  The  floor  of  the  mouth  Is  now  intact  and  the  left 
half  of  the  mandible  remains  iu  place  because  it  was  wired  to  the  maxilla  for  four  weeks 
after  the  resection.  The  patient  was  sent  home  at  this  time,  the  bare  areas  being  ready 
for  Thiersch  grafting. 

of  the  lip  has  been  removed,  the  plastic  operation  need  be  done  only 
on  the  same  side,  in  which  case  the  incision  in  the  cheek  would  be 
made  less  than  the  width  of  the  lip  defect.  The  incisions  (a-c  and 
c-b)  are  made  through  the  full  thickness  of  the  cheek,  the  point 
(c)  being  at  the  level  of  the  ala  of  the  nose.  From  the  triangular  flap 
(a-b-c)  the  skin  and  muscles  are  removed,  leaving  only  the  mucous 
membrane  and  its  submucous  tissue  attached  at  the  base  (a-b).  This 
flap  of  mucous  membrane  is  to  be  the  covering  of  the  free  border 
of  the  new  lip.  It  now  remains  to  free  the  cheek  so  that  the  lip  flap 
can  be  brought  to  the  median  line.  This  may  require  incising  the 
mucous  membrane  and  buccinator  muscle  along  the  full  length  of  the 
upper  fornix  and  along  the  inner  surface  of  the  masseter  muscle,  and 


262 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


also  some  undermining  of  the  cheek.  The  operation  is  done  on  both 
sides  if  more  than  three  fifths  of  the  lip  is  excised.  The  borders  of 
the  cuts  (a-c  and  c-b)  are  sutured,  the  new  lip  is  sutured  in  the 
median  line,  and  the  mucous  covering  of  its  free  border  adjusted. 
Drainage  should  be  provided  on  each  side  at  the  lower  border  of  the 


Fig.    227 


Fig.   228. 


Fig.    230. 


Fig.    229. 


Fig.    231. 


Fig.   227.      Tlie  Bui'ow-Stewart  operation  for  restoring  the  lower  lip. 

Fig.  228.  Sliowing  V-shaped  excision.  The  lines  of  the  excision  are  concave, 
which  causes  a  protrusion  rather  than  a  notch  at  the  site  of  excision  when  the  borders 
are  approximated. 

Fig.   229.      Showing  restoration  alter  V-.shaped  excision. 

Fig.   230.      Showing  possible  defect  after  excision  about  corner  of  mouth  and  chin. 

Fig.  231.     Restoration  after  excision  shown  in  the  preceding  figure. 


REPAIR  OF  ACQUIRED  DEFECTS. 


263 


flap.  With  a  V-shaped  excision  of  a  small  part  of  the  lip  this  pro- 
cedure is  not  necessary  (Figs.  238  and  229).  Except  for  very  early 
and  very  inactive  carcinomata,  the  V-shaped  excision  is  not  a  com- 
mendable procedure.  Figs.  230  to  235  show  other  plans  of  restoration 
of  the  lips  and  contiguous  structures. 


Fig.   232. 


Fig.   233. 


Fig.  234. 


Fig.   235 


Fig.   232.      Showing  possible  excision  of  corner  of  mouth. 

Fig.   233.     Restoration  after  excision  shown  in  preceding  figure. 

Fig.  234.  Showing  excision  about  lower  lip  and  chin,  with  median  incision  in  the 
neck  that  would  expose  the  submental  and  submaxillary  lymph  nodes.  The  neck  flaps 
are  undermined,  and  the  buccinator  and  mucosa  are  freed  along  the  lower  fornix,  (da) 
is  united  to  (de),  and  (o&)  is  united  to   (be). 

Fig.  235.  Showing  restoration  after  the  excision  shown  in  the  preceding  figure. 
Tils  leaves  the  lower  lip  redundant,  but  as  it  is  not  lined  with  mucous  membrane,  it 
will  contract. 


The  lower  lip  and  chin  may  be  restored  from  a  flap  turned  from 
the  neck  or  from  the  arm,  the  forearm  being  inclined  to  the  head 
(Tagliacozzi  method).  One  advantage  of  these  methods  is  that  the 
lower  end  of  the  flap  is  non-hair  bearing,  and  it  can  be  turned  over 
to  make  a  lining  for  the  lip. 


264  SURGERY  OF  THE  MOUTH  AND  JAWS. 

BONE  GRAFTS. 

Free  Bone  Grafts. — Free  bone  grafts  should  be  autogenous  and 
covered  with  as  much  periosteum  as  possible.  They  should  also  con- 
tain marrow  and  endosteum.  Free  bone  grafts  suitable  for  use  in 
filling  defects  of  the  lower  jaw  may  be  obtained  from  the  ribs,  tibia, 
crest  of  the  ilium,  or  scapula. 

In  using  free  bone  transplants,  absolute  immobility  must  be  se- 
cured by  fixing  the  lower  to  the  upper  teeth  in  occlusion.  The 
mucous  membrane  of  the  mouth  must  not  be  opened,  and  the  opera- 
tion must  not  be  attempted  until  all  infection  has  disappeared. 

Rib. — Free  periosteum-covered  sections  of  ribs  may  be  used.  If 
the  defect  is  at  the  symphysis,  the  angle  of  the  rib  may  be  made 
use  of  to  reproduce  the  contour  of  the  jaw. 

In  removing  a  piece  of  rib,  preferably  the  5th,  it  should  be  freed 
without  disturbing  the  periosteum  on  the  external  surface,  but 
posteriorly  should  be  loosened  subperiosteally.  The  piece  of  rib  may 
be  detached  by  means  of  rib-cutting  forceps  or  a  Gigli  saw.  The 
wound  is  closed  with  interrupted  catgut  for  the  deep  sutures,  and 
silk  for  the  skin. 

Tibia. — The  crest  of  the  tibia  should  never  be  removed  for  graft- 
ing, as  this  weakens  the  bone  and  is  liable  to  be  followed  by  frac- 
ture. The  graft  should  be  taken  from  the  flat  antero-internal  sur- 
face of  the  tibia,  and  should  involve  the  full  thickness  of  the  bone 
down  to  the  marrow  cavity. 

Crest  of  the  iliiiiii. — This  is  especially  adaptable  to  cases  where  the 
chin  has  been  lost,  as  it  can  be  readily  fashioned  to  resemble  a  new  chin. 

After  exposing  and  trimming  the  ends  of  the  fragments  of  the 
jaw  bones,  the  bone  graft  may  be  fixed  in  place  either  by  metal  wires 
or  plates,  or  preferably  by  means  of  heavy  catgut  or  kangaroo-tendon 
sutures.  Intermaxillary  fixation  should  be  maintained  for  at  least 
two  months  after  bone  grafting. 

Cartilage  Grafts. — In  reconstructive  surgery  of  the  bones  of 
the  head,  and  particularly  of  the  jaws,  we  are  indebted  chiefly  to 
Morestin,  of  Paris,  for  calling  attention  to  the  adaptability  of  costal 
cartilage  in  replacing  lost  bony  tissues  following  war  injuries.  The 
Gth,  7th,  and  8th  costal  cartilages  are  usually  employed  for  this  pur- 
pose (Fig.  23G).  Costal  cartilage,  unlike  bone,  can  be  readily  trim- 
med or  cut  to  any  size  or  shape  with  a  knife,  while  at  the  same  time 
it  is  sufficiently  resistent  to  take  the  place  of  bony  tissue.  The 
cartilaginous  grafts  readily  attach  themselves  to  the  surrounding  soft 
tissues,  though  they  will  not  unite  with  bone.  Resorption  does  not 
take  place,  the  original  size  of  the  graft  being  maintained  indefinitely 
if   perichondrium   is   transplanted    with    the   cartilage.      The    removal 


REPAIR  OF  ACQUIRED  DEFECTS. 


265 


of  costal  cartilages  causes  practically  no  inconvenience  to  the  patient 
if  care  is  taken  to  close  the  wound  in  layers :  first  the  muscular  bed, 
then  the  superficial  aponeurosis,  and  finally  the  skin. 

Before  suturing,  the  intercostal  nerve  should  be  pulled  down  and 
cut  out.  If  these  precautions  be  observed  there  is  usually  no  com- 
plaint on  the  part  of  the  patient  of  pain,  dififiiculty  on  exertion,  re- 
spiratory trouble,  or  hernia.  It  may  be  necessary  sometimes  to  ligate 
the  internal  mammary  artery. 

Cartilage  that  is  derived  from  another  person  has  been  success- 
fully used  by  Morestin  even  w-hen  removed  as  long  as  a  month  previ- 
ous to  using  as  a  graft.  In  the  light  of  laboratory  experiments,  the 
ultimate  outcome  of  heterogeneous  cartilage  grafting  is  uncertain. 


Fig.   236.    .Diagrammatic    representation    of    tlie    right    costal    cartilage    from    which 
cartilaginous  grafts  may  be  obtained. 


If  infection  occurs  at  the  site  of  the  graft,  cartilage  is  not  so 
likely  to  be  lost  as  in  the  case  of  bone. 

In  free  cartilage  transplantation,  the  entire  operation  can  usually 
be  performed  under  local  anesthesia,  though  Morestin  advises  a  general 
anesthetic  for  the  first  stage  of  removing  the  costal  cartilage  from 
its  bed.  By  the  use  of  local  or  regional  anesthesia  the  danger  of  in- 
fection by  contamination  with  saliva  is  largely  eliminated ;  coopera- 
tion of  the  patient  is  assured,  and  the  operator  is  not  hindered  by 
the  presence  of  the  anesthetist. 

Repair  of  Defects  in  the  Upper  Jaw. — Costal  cartilage  may  be 
employed  for  building  out  the  face  after  loss  of  portions  of  the 
malar  and  maxillary  bones  following  gunshot  fractures  of  the  upper 


266  SURGERY  OF  THE  MOUTH  AND  JAWS. 

jaw.  Before  placing  the  cartilage,  the  wound  must  be  as  free  as 
possible  from  the  oozing  of  blood.  Several  pieces  of  cartilage,  shaped 
to  fill  the  breach,  may  be  used,  and  should  be  applied  to  one  another 
closely  with  flat  surfaces.  As  a  rule,  if  the  cartilage  is  cut  to  fit 
accurately  in  place,  it  requires  no  other  retention  than  that  afforded 
by  closure  of  the  wound  over  it.  If  bleeding  persists,  drainage  must 
be  provided  for  temporarily,  by  leaving  an  opening  in  the  skin  which 
is  usually  closed  after  24  hours. 

Repair  of  Defects  in  the  Lower  Jaw. — Before  filling  in  a  breach 
of  continuity  of  the  lower  jaw  with  a  cartilage  graft,  the  operation 
must  be  preceded  by  complete  reduction  of  the  vicious  attitude  of 
the  fragments,  and  a  reestablishment  of  the  articulation  of  the  teeth 
on  the  healthy  side.  Provision  must  be  made  for  maintaining  im- 
mobility of  the  jaw  during  and  after  operation.  This  is  obtained  by 
some  form  of  intermaxillary  fixation.  It  is  necessary  that  at  the 
time  of  placing  the  graft  there  be  no  forcible  effort  to  obtain  reduc- 
tion, as  this  might  lead  to  communication  of  the  wound  with  the 
mouth  cavity,  thus  rendering  useless  the  attempt  at  transplantation. 

In  replacing  a  defect  in  the  lower  jaw,  the  cartilage  is  selected 
and  shaped  to  the  required  size.  Where  part  of  the  ramus,  the  angle, 
and  horizontal  portion  of  the  bone  are  missing,  the  graft  is  formed 
from  the  6th  and  7th  costal  cartilages  of  the  saijie  side  removed  in 
one  piece.  The  posterior  extremity  of  the  6th  cartilage  will  become 
the  ascending  ramus,  that  of  the  7th  will  form  the  angle  of  the 
jaw,  while  the  fused  portion  of  the  two  cartilages  will  form  the 
horizontal  arch.  The  anterior  part  of  the  graft  is  trimmed  to  a  thin 
bevel  at  the  expense  of  its  inner  surface.  This  thinned  extremity 
must  extend  well  beyond  the  anterior  margin  of  the  breach,  in  order 
that  it  can  be  bent  back  on  itself  inwardly  and  applied  against  the 
anterior  fragment.  To  facilitate  this  incurvation  and  adaptation,  sev- 
eral incisions  are  made  across  the  bevelled  portion,  care  being  taken 
never  to  completely  interrupt  the  continuity  of  the  perichondrium. 
Final  trimming  of  the  graft  is  done  after  it  is  installed  in  the  wound. 

Preparation  of  Wound  for  Reception  of  the  Graft. — The  direc- 
tion of  the  operative  incision  is  governed  by  the  disposition  of  scars, 
which  are  excised,  and  the  wound  enlarged  if  necessary  to  expose 
and  free  the  extremities  of  the  bony  fragments.  Their  distance  apart 
is  measured  and  the  graft  trimmed  accordingly. 

Posteriori)',  between  the  masseter  on  the  one  hand,  and  the 
internal  pterygoid  and  what  remains  of  the  ascending  ramus  on  the 
other,  a  deep  excavation  is  made  which  will  receive  the  posterior 
portion  of  the  cartilage.  In  front  a  similar  cavity  of  reception  is 
made  by   turning  back   the   periosteum   of   the   outer   surface   of  the 


REPAIR  OF  ACQUIRED  DEFECTS.  267 

anterior  fragnient,  forcing  back  at  the  same  time  all  soft  parts.  The 
graft,  with  its  tapered  end  curved  over,  is  then  sprung  into  place. 
The  masseter  is  brought  over  the  cartilage,  spread  and  drawn  down 
as  much  as  possible,  and  fastened  to  the  graft  by  a  series  of  catgut 
sutures,  which  serve  to  fix  it  solidly  in  good  position.  For  this  work 
a  strong  needle  is  required.  At  any  points  where  a  hold  can  be  ob- 
tained on  the  fibrous  and  muscular  tissue,  sutures  of  catgut  are  placed, 
fixing  the  cartilage.  The  anterior  end  of  the  cartilage  is  also  fixed 
to  the  soft  tissues  with  sutures.  The  superficial  wound  is  closed 
without  drainage.  Fixation  of  the  lower  to  the  upper  jaw  is  main- 
tained for  several  weeks. 

It  is  usually  found  at  the  end  of  this  time,  that  while  there  is  no 
absolute  union  between  the  ends  of  the  bone  and  the  cartilage,  yet 
for  functional  purposes  the  slight  mobility  is  of  little  or  no  con- 
sequence. 

Semipedicled  Bone  Grafts  taken  from  the  immediate  neighbor- 
hood of  the  site  of  the  defect  were  suggested  by  Oilier.  Recently 
Cavalie  has  applied  this  principle  to  the  treatment  of  defects  of  the 
lower  jaw  following  gunshot  injury.  By  employing  bone  taken  from 
the  immediate  vicinity,  the  graft  has  the  advantage  of  possessing  the 
same  texture,  bone  and  periosteal  cells,  and  disposition  of  blood 
supply  as  the  fractured  fragments. 

The  various  steps  of  the  method  are  as  follows : 

1.  Opening  through  the  skin  at  the  seat  of  fracture. 

2.  Baring  of  the  end  of  each  of  the  fragments  without  touching 
the  periosteum,  over  an  extent  necessary  for  removal  of  grafts. 

3.  Clearing  of  the  seat  of  fracture,  taking  care  not  to  open  the 
buccal  cavity,  which  may  provoke  suppuration. 

4.  Freshening  the  two  surfaces  of  the  fracture  with  the  rongeur. 

5.  Cutting  of  grafts  from  one  or  both  external  tables  of  the  frag- 
ments. 

(a)  If  the  bony  breach  is  less  than  3  or  3  cm.,  it  suffices  generally 
to  have  only  one  graft  which  can  be  cut  long  enough  from  one 
fragment. 

(b)  If  the  bony  gap  is  over  2  or  3  cm.  wide,  it  may  be  necessary 
to  cut  a  graft  from  each  fragment  and  to  unite  them  in  the  middle 
of  the  breach. 

MctJwd  of  Ciitting  the  Graft. — If  the  graft  is  to  be  cut  from  the 
anterior  fragment,  the  lower  bridge  of  union  between  the  outer  and 
inner  tables  is  severed  with  forceps.  The  outer  plate  is  then  separated 
by  passing  a  flat,  narrow  chisel  into  the  spongy  tissue,  and  the  anterior 
limit  of  the  graft  is  severed  with  the  chisel  and  mallet.  The  separated 
graft  is  then  slid  over  until  its  edge  penetrates  between  the  two  tables 


268 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Fig.    237.      Transplantsition   of  bone   to   repair   bony   defect   of   jaw   at   chin,    showing 
implanted  piece  of  rib  in  position. 


Fig.  238  Tran.splantation  of  portion  of  bone  to  repair  bony  defect  of  jaw  at  chin. 
Raising  the  flap  at  second  operation.  Note  the  toothed  forceps  which  hold  flap  at  site 
where  bone  is  implanted. 


REPAIR  OF  ACQUIRED  DEFECTS. 


269 


into  the  cancellated  tissue  of  the  posterior  fragment,  while  the  other 
end  still  rests 'in  contact  by  its  deep  spongy  surface  with  the  substance 
of  the  fragment  of  origin.  Some  periosteal  fibers  are,  if  possible, 
allowed  to  remain  to  unite  the  graft  with  the  fragment  of  origin. 
Sometimes  the  graft  may  be  reversed  on  the  fractured  end  as  a  hinge. 

6.  The  fragments  are  united  to  the  graft  with  catgut  sutures,  and 
the  skin  closed. 

It  is  necessary  to  accurately  reduce  the  fragments  previous  to  the 
operation,  and  to  maintain  immobilization  by  intermaxillary  fixation 
for  several  weeks. 


Fig.  239.  Transplantation  of  portion  of  bone  to  repair  bony  defect  of  jaw  at  chin. 
The  flap  is  turned  into  place  and  the  unplanted  bone  ends  are  fastened  to  the  freshened 
end   of   the   jaw   fragments. 

Combined  Pedicled  Bone  and  Soft  Tissue  Grafts. — If  there  is  a 
complete  defect  in  the  mental  portion  of  the  lower  jaw,  this  can  be 
repaired  in  one  or  two  ways.  The  bone  defects  may  be  compensated 
by  the  splint,  as  shown  in  Fig.  67,  and  the  soft  tissues  repaired  as 
described  in  a  previous  section. 

Another  method  is  to  transplant  a  piece  of  the  angle  of  the  8th  or 
9th  rib  into  a  proper  place  in  the  neck  between  the  skin  and  platysma 
and  allow  it  to  heal  in  place ;  then  three  or  four  weeks  later  a  flap  is 
raised  from  the  neck,  including  the  platysma,  and  with  it  the  implanted 


270 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


bone  fragment,  exposing  only  the  ends  of  the  latter.  The  location  in 
the  neck  into  which  the  rib  segment  is  planted,  and  the  flap  itself  should 
be  so  planned  that  when  finally  put  in  place,  the  rib  segment  falls 
naturally  into  its  new  position.  Besides  the  direct  wiring,  the  soft 
tissue  flap  should  tend  to  steady  the  bone  graft  in  its  new  position 
rather  than  drag  upon  it.    (Figs.  237,  238,  and  239.) 

Another  plan  is  to  extend  the  neck  flap  to  10  cm.  below  the  clavicle 


Fig.   240.      Lateral   implantation  of  osteoplastic  flap  from  clavicle. 

This  metliod  is  applicable  in  closing  a  defect  of  the  bone  and  superimposed  soft  tissue 
and  offers  the  advantage  of  using  a  bone  transplant  which  retains  its  original  blood  sup- 
ply.    It  is  more  applicable  to  defects  on  the  labial  surfaces  of  the  face  or  the  nose. 

The  mucous  and  skin  surfaces  have  been  drawn  towards  each  other  by  scar  which 
is  to  be  freely  removed  so  that  the  remaining  normal  tissues  may  be  restored  tcr  their 
natural  positions,  giving  broad  raw'  surfaces  for  the  reception  of  the  borders  and  under 
surface  of  the  flap.  Special  care  is  to  be  exercised  to  retain  and  preserve  all  of  the 
mucous  membrane  so  that  it  can  be  used  to  at  least  partially  line  the  new  cheek  flap.  The 
ends  of  the  mandible  are  to  be  freshened  and  drilled.  The  mandible  must  be  firmly 
fastened    to   the   maxilla.      A    Herpin    splint   might    be    incorporated    with    this. 


on  the  opposite  side,  and  in  turning  up  the  flap  to  include  a  thin  sur- 
face graft  from  the  clavicle  without  detaching  it  from  the  under  sur- 
face of  the  flap  (Fig.  241).  The  detachment  of  the  piece  of  clavicle 
can  be  done  with  a  Hay  saw  or  a  surgical  engine.  When  this  flap 
is  turned  into  place,  the  bone  fragment  is  attached  to  the  free  ends  of 
the  mandibular  body  and  the  .soft  tissues  are  arranged  so  as  to  repair 


REPAIR  OF  ACQUIRED  DEFECTS. 


271 


the  lip  and  chin  or  the  body  of  the  mandible  and  cheek  (Figs.  840,  and 
341).  If  so  much  of  the  chin  is  missing  that  even  after  grafting  the 
chin  will  be  noticeably  short,  then  it  might  be  advisable  to  lengthen 
the  body  of  the  jaw  on  each  side  by  subcutaneous  section  of  the  ramus, 


Fig.  241.  Lateral  implantation  of  osteoplastic  flap  from  the  neck  and  clavicle. 
In  the  defect  illustrated,  before  placing  the  graft,  the  borders  of  the  mucosa,  which 
by  sca'r  contraction  have  been  drawn  into  the  wound,  are  entirely  freed  and  the  edges 
tacked  to  the  under  surface  of  the  flap  in  appropriate  places.  Then  the  cut  surface  of 
the  bone  graft  is  placed  against  the  freshly  cut  raw  surface  of  the  mucosa  flap  with 
free  drainage  established  from  below.  This  reproduces  the  condition  of  a  well-drained 
compound  fracture.  As,  in  all  neck  pedicle  flaps,  the  platysma  myoides  muscle  is  included 
with  the  skin.  When  the  clavicle  is  encountered,  great  care  is  taken  not  to  separate  the 
soft  tissues  from  the  graft.  The  bone  is  cut  with  a  motor  saw  and  chisel  and  as  soon 
a3  loosened  the  graft  is  grasped  with  osteoplastic  forceps  to  prevent  the  graft  being  sepa- 
rated from  the  flap.  The  skin  defect  in  the  neck  is  immediately  closed  by  drawing  the 
skin    borders    together    with    or    without    compensatory    incision.       (See    Pig.    180.) 


as  shown  in  Chap.  XXI,  before  grafting  is  done.  To  do  this  later 
might  fracture  the  jaw  at  the  site  of  the  graft.  If,  after  doing  this, 
the  chin  is  still  short,  costal  cartilage  might  be  implanted  as  described 
on  page  264. 


2'/3 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Grafting-  by  either  of  the  above  methods  has  the  advantage  that 
the  nutrition  of  the  bone  fragments  is  already  provided  for  and  that 
the  graft  can  be  implanted  in  a  non-aseptic  area,  and  the  site  of  union 
treated  as  an  open  fracture  with  full  provision  for  drainage. 

Using  the  extremely  curved  part  of  the  8th  or  9th  rib  at  the  angle 
helps  to  round  out  the  chin.  The  clavicular  graft  can  also  be  used  to 
repair  a  lateral  bone  and  soft  tissue  defect. 

In  contemplating  such  operations,  unless  one  is  familiar  with  this 


Fig.  242.  Shows  method  used  to  grasp  the  jaw  through  the  intact  skin  to  draw 
it  forward  so  as  to  get  the  teeth  in  the  lower  fragment  into  normal  relation  with  those 
in  the' upper  jaw.      Fig.  A.  Forceps  used   in  method  described. 

work  it  is.  well,  if  possible,  to  first  carry  out  the  procedures  on  the 
cadaver.  Unless  the  surgeon  feels  able  to  visualize  the  various  steps 
of  such  an  operation,  it  is  probably  better  to  resort  to  the  use  of  the 
Marten  type  splint  for  the  bone  defect  and  make  the  soft  tissue  repair 
over  this.  This  gives  very  good  permanent  results  and  is  much  less 
trying  on  the  patient  and  operator. 

Fixation  of  the  Maxilla. — If  there  has  been  much  destruction  of 
the  bones  above  the  palate,  even  after  fixation  for  weeks  according  to 
the  methods  described  under  fractures  of  the  maxilla,  the  tooth-bear- 
ing portion  of  this  bone  may  lack  union  anteriorly  so  that  it  will  move 


REPAIR  OF  ACQUIRED  DEFECTS.  273 

up  and  down  during  efforts  at  mastication.  This  is  best  remedied  by 
connecting  the  palatal  and  alveolar  part  of  the  maxilla  to  the  firm  bone 
above  with  a  bridge  or  one  or  two  bone  or  cartilage  grafts  let  in  from 
the  face  surface.  If  there  is  also  an  extensive  destruction  of  the  soft 
tissues  over  the  bodies  of  the  maxillae,  bone  or  cartilage  grafts  may 
be  previously  set  into  the  flaps  to  be  used  in  repairing  the  face. 

Transplantation  of  Portion  of  Bone  to  Repair  Bony  Defect  of 
Lov^^er  Jaw  at  Chin.; — A  portion  of  the  rib  at  the  angle  is  to  be 
removed.  It  is  to  be  just  long  enough  to  fill  in  the  bony  defect,  there- 
fore the  defect  should  be  measured;  of  course  if  too  long  it  can  be 
easily  shortened  at  the  second  operation.  The  removal  of  the  rib  is 
done  as  in  an  ordinary  thoracotomy,  except  that  the  wound  is  to  be 
closed  later.  The  pleura  is  not  to  be  opened  and  the  bone  has  to  be 
removed  with  its  periosteum  intact;  this  should  be  neither  cut  nor 
bruised.  When  the  piece  has  been  removed,  it  is  not  to  be  touched 
even  with  gloved  fingers,  but  is  held  in  an  instrument  w^hile  muscle 
fragments  are  being  removed  and  may  be  returned  to  the  original 
wound  and  covered  over  w'hile  its  bed  is  being  prepared.  The  best 
site  for  implantation  is  a  fingerbreadth  above  the  clavicle,  just  over  the 
lower  end  of  the  sternomastoid.  It  is  well  to  mark  on  the  skin  the 
outlines  of  the  flap  to  be  raised  at  the  next  operation.  A  vertical  incision 
one  inch  long  is  made  through  the  skin  about  a  fingerbreadth  above 
the  clavicle  and  cut  down  until  the  platysma  is  seen.  With  blunt- 
pointed  scissors  a  passageway  is  cut  between  fat  and  platysma  for- 
ward toward  the  middle  line  parallel  with  the  clavicle.  This  passage- 
way is  widened  with  scissors  so  as  to  make  a  channel  big  enough  to 
easily  accommodate  the  portion  of  the  rib  to  be  implanted.  Be  sure 
that  the  skin  incision  is  wide  enough  to  admit  passage  of  the  piece  of 
bone.  The  portion  of  rib  is  now  grasped  with  forceps  and  carefully 
pushed  into  this  canal,  care  being  taken  that  its  edges  do  not  come  in 
contact  with  the  skin.  Be  sure  the  skin  over  it  is  not  too  tight  else 
sloughing  will  ensue.  If  too  tight  the  rib  is  taken  out  and  the  chan- 
nel made  larger.  The  skin  wound  is  now  closed.  When  healing  is 
firm,  the  second  step  of  the  operation  may  be  undertaken. 

Accurate  measurement  is  made  of  the  bony  defect  to  be  bridged, 
first  being  sure  that  fragments  of  the  jaw  are  fixed  in  their  normal 
position  (Fig.  242).  The  teeth  may  be  wired  to  those  in  the  upper 
jaw.  The  edges  of  the  original  wound  are  freshened,  dissecting 
mucous  membrane  from  skin  attachment.  The  tongue  must  be 
loosened  so  as  to  be  returnable  into  the  oral  cavity.  The  flap  is  to  be 
long  enough  so  that  the  part  which  projects  beyond  the  implanted  rib 
will  be  twice  the  distance  from  the  upper  margin  of  the  transplanted 
rib  to  the  edge  of  the  lower  lip,  since  this  portion  is  to  be  folded  on 


274  SURGERY  OF  THE  MOUTH  AND  JAWS. 

itself  to  make  a  new  lower  lip.  This  will  carry  the  incision  for  the  flap 
well  over  the  clavicle.  Be  sure  the  pedicle  is  wide  enough.  The  flap 
includes  the  platysma — it  had  best  not  include  the  cervical  fascia — 
and  is  dissected  and  turned  well  up.  The  flap  is  then  rotated  and 
turned  into  place  so  that  the  ends  of  the  rib  come  into  contact  with 
the  ends  of  the  jaw  fragments.  If  the  rib  is  too  long,  it  should  be 
nipped  ofif  from  each  end  with  a  rongeur;  in  any  case  its  ends  must  be 
freshened  and  holes  for  wires  made.  While  the  bone  is  held  in  place, 
the  projecting  portion  of  the  flap  is  turned  over  to  form  the  lower  lip 
and  its  free  edge  sewed  to  the  cut  edge  of  mucosa  under  the  tip  of  the 
tongue ;  this  can  be  done  either  from  above  or  below.  A  loop  of  silk- 
worm gut  is  passed  around  the  middle  of  the  transplanted  bone,  leav- 
ing the  loop  loose  enough  inside  to  pass  thread  through.  A  needle  is 
then  passed  through  the  geniohyoid  and  geniohyoglossus  at  their  at- 
tachments to  the  tongue.  The  tongue  is  pulled  forward  and  fastened 
to  this  loop  with  two  or  three  stitches.  The  bones  are  now  wired  with 
fine  silver  wire  through  the  previously  drilled  holes.  A  drain  is  placed 
in  the  cavity  under  the  tip  of  the  tongue  behind  the  transplanted  rib 
and  brought  out  below.  A  tight  closure  is  made  between  the  edge  of 
the  flap  and  the  floor  of  the  mouth.  The  folded  portion  of  the  flap  is 
now  drawn  up  so  that  its  raw  surfaces  approximate,  thus  making  a 
lower  lip.  Stitches  are  now  taken  between  this  fold  and  what  is  to  be 
the  angle  of  the  mouth  and  the  remaining  free  edges  of  the  flap  are 
sewed  to  the  freshened  edges  of  the  skin  defect.  Again  care  should  be 
taken  that  the  pedicle  is  not  constricted.  If  it  twists  tightly,  it  should 
be  loosened  farther  back,  especially  along  the  posterior  incision,  ex- 
tending this  as  high  as  is  necessary. 

Flap  From  Forehead  to  Fill  Defect  in  Cheek. — Measurement 
of  the  defect  should  be  made  allowing  one-third  for  shrinkage.  The 
flap  is  outlined  on  the  forehead,  and  arranged  so  that  the  anterior 
branch  of  the  temporal  artery,  or  temporal  artery  itself,  runs  in  the 
pedicle.  It  is  desirable  to  have  the  flap  from  the  forehead  only,  but 
if  the  defect  be  too  large  the  flap  may  extend  up  beyond  the  hair  line. 
The  edges  of  the  defect  are  freshened,  incision  being  made  where  the 
skin  becomes  continuous  with  the  mucous  membrane,  the  mucous 
membrane  turned  inward  around  the  edges.  The  flap  is  cut,  includ- 
ing in  it  all  tissues  down  to  the  pericranium,  and  is  then  swung 
and  turned  downward  so  that  the  raw  surface  will  lie  outward,  taking 
care  that  the  pedicle  is  not  too  abruptly  twisted  lest  this  interfere  with 
the  return  flow.  If  the  twist  seems  too  abrupt,  the  pedicle  can  be  cut 
and  loosened  still  farther  down.  Good  hemostasis  should  be  estab- 
lished ;  large  vessels  should  be  tied  with  plain  catgut,  and  smaller  ones 


REPAIR  OF  ACQUIRED  DEFECTS. 


275 


"twisted."  The  flap  is  now  in  place  and  the  skin  stitched  to  the 
loosened  mucous  membrane. 

The  defect  on  the  forehead  may  now  be  skin  grafted,  as  may  also 
the  outer  raw  surface  of  the  flap ;  or  if  the  operator  prefers,  he  may 
dress  both  wounds  and  do  skin  grafting  after  granulation  has  begun — 
say  six  to  ten  days.    The  pedicle  should  not  be  cut  until  healing  is  firm. 

Flap  From  Clavicle  to  Repair  Defect  in  Jaw. — The  length  of 
the  bone  defect  should  be  measured.  A  long  flap  with  its  pedicle 
above,  and  either  backward  on  the  same  side  or  backward  and  to  the 


^ 


C5C 


Fig.   243.     Author's  methcd    of  repairing  defect   due   to   scar  tissue. 

opposite  side  across  the  middle  line,  should  be  outlined.  The  convex 
edge  of  the  flap  should  project  below  the  clavicle  for  a  distance  of  at 
least  one  inch.  This  flap  must  be  long  enough  so  that  when  turned  on 
itself  and  brought  up  to  the  place  where  the  defect  is  to  be  repaired 
it  will  not  twist  abruptly.  Included  in  the  flap  are  the  skin  and 
platysma.  The  flap  is  reflected  as  far  as  the  lower  margin  of  the 
clavicle  only.  On  no  account  must  it  be  separated  from  the  un- 
derlying clavicle.  All  bleeding  is  controlled.  Incisions  should  be 
deepened  where  they  cross  the  clavicle  until  the  bone  is  bared.     The 


^ 


^ 


^  B  C 

Fig.  244.     Esser's  method  of  repairing  defect  due  to  scar  tissue. 

skin  is  retracted,  care  being  taken  not  to  touch  the  flap,  so  as  to 
expose  the  clavicle.  The  clavicle  is  cut  into  with  a  saw  to  a  depth  of 
one-half  centimeter  at  each  side  of  the  flap.  The  edge  of  the  reflected 
flap  is  now  turned  up  so  as  to  expose  the  lower  aspect  of  the  clavicle. 
With  a  saw  the  clavicle  is  cut  longitudinally  between  the  bottoms  of 
saw-cuts  previously  made  in  it,  thus  cutting  out  a  portion  of  the 
clavicle  where  it  is  crossed  by  the  flap.  A  blunt  protector  should  be 
passed  behind  the  clavicle  to  prevent  injury  to  important  structures 
while  sawing.     The  bone  and  flap  are  now  grasped  (Fig.  2ttl),  so  as 


276 


SURGERY  OF  THE  ^lOUTH  AND  JAWS. 


to  prevent,  if  possible,  accidental  separation  of  the  bone  from  the  flap. 
On  no  account  must  these  clamps  be  removed  until  the  bone  and  flap 
have  been  sewn  into  place.  The  remaining  part  of  the  flap  is  now 
loosened,  bleeding  controlled,  and  the  flap  is  turned  upward,  the  bone 
first  fastened  into  place  by  passing  silver  wires  through  the  previously 
drilled  holes.  Should  there  be  constriction  where  the  pedicle  is 
twisted,  the  pedicle  is  loosened  still  more.  It  is  better  to  use  inter- 
rupted stitches  in  closing  the  soft  parts.  The  area  from  which  the 
flap  has  been  removed  may  be  covered  with  iodoform  gauze  or  balsam 
of  peru  and  allowed  to  granulate  and  later  skin  grafted.  If  the  flap 
has  not  been  a  very  wide  one,  it  may  be  possible  to  close  the  defect 
bv  undercutting-. 


Fig.  245.  Restoration  of  the  upper  lip.  The  triangles  (e  /  g)  are  excised  to  the 
bone,  (e  /)  being  half  the  distance  from  (e)  to  (e) .  In  excising  the  triangles  (a  b  c) , 
the  mucous  membrane  and  submucous  tissue  is  left  attached  to  the  new  flap  at  (a  b). 
(a  6)  on  each  side  is  to  be  half  the  width  of  the  lip  defect.  After  undermining  the 
tissues  (see  Restoration  of  Lower  Lip),  the  raw  edges  (a  e)  and  (a  e)  are  sutured  in 
the  naidline,  the  now  linear  cuts  above  and  below  are  closed,  and  the  mucous  flaps  ad- 
justed to  the  free  border  of  the  new  lip. 


DEEP  SCARS  ON  THE  FACE. 

After  deep  injuries  of  the  face  have  healed  or  after  extensive 
grafting  operations,  the  face  may  be  much  disfigured  either  by  raised 
or  depressed  scars. 

If  a  scar  shows  keloid  tendencies,  either  radium  or  x-ray  treat- 
ment should  be  used. 

If  the  scar  is  rough  and  white,  it  may  be  excised  and  better  ap- 
proximation obtained. 

Depressed  scars  are,  as  a  rule,  best  dealt  with  by  dissecting  out  all 
scar  tissue,  and  after  freeing  the  tissues,  building  up  the  defect  by 
approximating  the  walls  as  if  one  were  repairing  a  cut  in  which 
primary  union  was  expected.  The  schematic  drawings  (Figs.  243  and 
244)  show  how  this  may  be  done. 


REPAIR  OF  ACQUIRED  DEFECTS. 


277 


In  rare  cases,  where  the  depression  in  the  soft  tissues  cannot  be 
obhterated  in  the  manner  just  shown,  transplantation  of  small  pieces 
of  fat  from  the  abdominal  wall  may  be  resorted  to^  The  cutaneous 
incision  in  the  region  of  the  defect  should  not  be  large,  and  should  be 
placed,  if  possible,  at  some  inconspicuous  point.  The  subcutaneous 
tissues  are  separated  by  a  knife,  and  by  tunneling  with  blunt-pointed 
scissors.  After  the  arrest  of  hemorrhage,  bits  of  fat  of  sufficient  size 
are  introduced  and  held  in  the  pocket  by  subcutaneous  sutures  of  fine 
catgut.     It  is  usually  undesirable  to  suture  the  fat  in  position. 

Practically  all  of  these  minor  plastic  operations  can  be  done  under 
local  anesthesia. 

RESTORATION  OF  THE  UPPER  LIP. 

The  upper  lip  can  be  reconstructed  by  the  plan  shown  in  Fig.  245. 


Fig.    246. 


Fig.    247. 


Fig.   246.      Diagram  of  defect  in  hard  palate. 

Fig.  247.  Restoration  of  defect  shown  in  preceding  figure,  showing  relative  extent 
of  the  lateral  incisions. 

PERFORATIONS  OF  THE  PALATE. 

When  not  due  to  gunshot  injuries,  these  are  nearly  always  syphi- 
litic and  may  vary  from  linear  defects,  surrounded  by  absolutely  normal 
tissue,  to  loss  of  most  of  the  palate  processes  and  all  of  their  mucous 
coverings. 

Small  defects  in  the  palate,  up  to  the  size  of  the  end  of  a  finger, 
are  easily  closed  by  making  a  lateral  incision  down  to  the  bone  on  each 
side  as  close  to  the  teeth  as  is  possible  without  exposing  the  necks. 
The  mucoperiosteal  covering  is  raised,  as  in  making  flaps  for  repairing 
a  congenital  cleft.  The  edges  of  the  defect  are  freshened  and  sutured 
together  (Figs.  240  and  247).     If  the  palatine  arteries  are  uninjured 


278  SURGERY  OF  THE  MOUTH  AND  JAWS. 

and  have  been  raised  with  the  flap,  the  lateral  incisions  may  be  made  to 
approach  each  other  very  closely  in  front.  These  perforations  extend 
into  the  nose ;  the  nasal  discharge  may  be  prevented  from  accumulating 
above  the  palate  flap,  and  drainage  is  assured  by  passing  a  piece  of 
rubber  dam  from  the  mouth  through  the  lateral  incision  between  the 
flap  and  the  bone  on  each  side. 

For  more  extensive  perforations  some  plan  of  flap  transplantation 
will  have  to  be  adopted   (Chap.  XII). 

It  has  been  recommended  to  treat  small  perforations  by  freshening 
the  edges  with  the  actual  cautery  and  allowing  the  hole  to  close  h\ 
granulations  and  scar  contraction.  For  holes  up  to  the  size  of  a 
pea  in  the  velum,  this  will  be  effective,  but  we  have  never  had  much 
success  with  it  in  the  hard  palate,  even  with  the  smallest  openings. 

The  variations  in  the  procedures  that  may  be  resorted  to  for  repair 
of  defects  is  almost  unlimited,  but  the  preceding  gives  an  outline  that 
will  suggest  certain  possibilities. 

AFTER-TREATMENT. 

After  operation  on  the  face,  if  possible,  for  the  first  few  days 
the  patient  should  be  kept  in  a  position  that  will  allow  the  saliva  to 
drain  away  from  the  wounds,  and  no  external  dressing  is  to  be  applied 
to  face  wounds.  In  summer  any  exposed  space  under  a  pedicle  should 
be  carefully  packed  with  gauze.  It  is  difficult  to  keep  light  summer 
dressings  in  absolute  contact  with  the  under  surface  of  the  chin,  and 
it  would  be  embarrassing  to  find  neck  spaces  fly-blown. 


;  ICHAPTER  XX. 

IDEAL  OCCLUSION  AND  MALOCCLUSION  OF  THE 

TEETH— IRREGULARITIES   IN  THE  GROWTH 

AND  RELATION  OF  THE  JAWS. 

The  relation  of  the  upper  and  lower  dental  arches  to  each  other, 
as  well  as  the  positions  of  the  individual  teeth  in  each  arch,  influence 
and  are  influenced  by  the  size,  shape,  and  positions  of  the  jaws.  It  is 
for  this  reason  that  occlusion  and  malocclusion  must  be  considered  to- 
gether with  deformities  and  malrelations  of  the  jaws   (Fig.  248). 


Fig.  248.  X-ray  showing  a  very  much  undeveloped  .law  of  a  young  woman,  twenty- 
two  years  old,  who  at  the  age  of  three  years  lost  the  teeth  and  a  portion  of  the  upper 
border  of  the  body  from  necrosis,  evidently  all  of  the  germs  of  the  permanent  teeth  ex- 
cept those  of  the  third  molars.  The  latter  teeth  are  seen  to  be  the  only  ones  that  have 
developed.  The  body  of  the  jaw  has  developed  but  little  since  it  suffered  the  injury. 
The  lower  third  molar  can  be  seen  growing  apparently  from  the  ramus.  This  case  was 
referred  to  us  by  Dr.  L.  S.  Chaudet.  The  offer  to  attempt  to  graft  a  rib  in  the  lower 
jaw  to  allow   her  to   use  artificial   teeth  was   refused. 

IDEAL  OCCLUSION. 

What  has  come  to  be  considered  the  ideal  occlusion  is  a  condition 
in  which  the  crowns  of  the  upper  incisor  teeth  slightly  overlap  the 
lower;  in  which  the  individual  lower  teeth  are  partly  in  advance  of 
the  corresponding  teeth  of  the  upper  jaw;  and  in  which  the  crowns  of 
the  lower  molars  are  slightly  nearer  the  mesial  plane  than  are  their 
fellows  above,  so  that  the  lingual  cusps  of  the  upper  teeth  fit  between 

279 


280 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  buccal  and  lingual  cusps  of  the  lower  (Fig.  249).  The  individual 
lower  teeth  are  closer  to  the  symphysis  than  the  upper,  because  the 
crowns  of  the  lower  central  incisors  are  nrxrrower  than  the  corre- 
sponding upper.  As  a  result  of  this,  the  lower  canine  and  bicuspids  and 
cusps  of  the  molars  are  each  just  in  advance  of  its  fellow  above.  In 
spite  of  the  greater  width  of  the  lower  jaw,  the  lingual  cusps  of  the 
lower  molars  occlude  to  the  inner  side  of  the  upper,  by  reason  of  the 
obliquity  at  which  the  lower  molars  are  set  (Fig.  8). 

MALOCCLUSION. 

The  term  malocclusion  is  commonly  used  in  reference  to  the  perma- 
nent dentition  only.  It  may  indicate  any  irregularity  in  the  alignment 
of  the  teeth  in  either  or  both  jaws,  or  an  irregularity  in  the  relation  of 


Molar. 


Incisor 


Fig.  249.  Occlusion  of  the  teeth  viewed  from  behind.  It  will  be  observed  that  the 
lingual  cusps  of  the  lower  molar  occlude  slightly  mesial  to  the  lingual  cusps  of  the 
upper,  and  that  the  incisor  occlude  behind  the  corresponding  upper  teeth. 

the  teeth  in  one  jaw  to  those  in  apposition.  The  latter  condition  may 
be  due  to  a  disproportion  in  the  jaw-bones,  and  it  is  not  necessarily 
accompanied  by  any  irregularity  in  the  alignment  of  the  teeth.  It  is 
a  subject  of  primary  interest  to  the  orthodontist,  but  to  the  surgeon  only 
in  so  far  as  the  irregularity  is  an  indication  or  a  cause  of  bony  de- 
formity not  confined  to  the  alveolar  processes.  All  malocclusions  should 
receive  consideration,  and  their  prevention  is  of  greater  importance. 

CAUSES  OF  IRREGULAR  SETTING  OF  THE  TEETH. 

Among  the  many  causes  to  which  irregular  setting  has  been 
ascribed,  some  are  rather  difficult  of  proof  and  hardly  within  our  direct 
control.  But  there  are  three  that  are  quite  tangible,  and  some  one  of 
these  is,  no  doubt,  responsible  for  almost  all  of  the  cases.  These  are: 
(1)   Abnormal   pressure   on  the   erupted   crowns,    such  as   continued 


MALOCCLUSION  AND  IRREGULARITIES.  281 

thumb-sucking,  tongue-sucking,  lip-biting,  scar  contraction,  etc.  (2) 
The  withdrawal  of  normal  counterpressure — the  most  common  instance 
of  this  is  mouth-breathing — where  the  pressure  of  the  cheeks  upon  the 
outer  surface  of  the  upper  teeth  is  not  counterbalanced  by  the  tongue, 
as  it  is  when  the  mouth  is  closed.  (3)  The  premature  removal  of 
the  deciduous  and  permanent  teeth,  by  deranging  the  natural  spacing, 
is  responsible  for  many  irregularities  in  the  setting  of  the  second  set 
of  teeth  (Fig.  250).  Irregular  dentition  is  another  cause,  but  it  is  one 
over  which  we  have  little  control.  The  bearing  of  atavism  will  be  con- 
sidered in  the  next  paragraph. 

MALRELATION  OF  THE  DENTAL  ARCHES  AND  OF 

THE  JAWS. 

Moderate  irregularity  of  the  erupting  teeth  in  front  of  the  perma- 
nent molars  is  usually  spontaneously  corrected.     But  malrelations  be- 


Fig.   250.      Showing  deformity  of  the  jaw  due  to  early  extraction  of  the  first  perma- 
nent molar  tooth. 

tween  the  upper  and  lower  first  permanent  molars,  if  untreated,  are 
often  followed  by  increasing  malrelation  of  the  jaws  themselves.  In 
some  cases  the  malrelation  of  the  teeth  is  primary  deformity,  but 
we  believe  it  may  be,  for  a  time,  simply  the  first  noticeable  indication 
of  disproportion  in  the  bony  arches.  It  is  only  later  that  the  lack  of 
proper  intermeshing  of  the  teeth  becomes  a  factor  in  the  continuously 
increasing  deformity.  We  believe  that  atavism  may  be  the  primary  fac- 
tor in  some  cases.  When  the  world  was  younger  and  the  nations  did 
not  mix,  very  distinct  facial  types  were  developed  and  preserved.  In  the 
higher  of  these  types  the  lower  part  of  the  face  was  proportionately 
small  and  protrvided  but  little  (Fig.  2.51).  In  others,  less  removed  from 
the  animal  type,  the  jaws  were  the  predominant  features  (Fig.  252). 
The  present  generation  of  white  Americans  is  essentially  a  mixed  race, 
and  if  we  will  grant  that  we  can  inherit  dififerent  features  from  diflferent 


282 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


ancestors,  we  think  it  must  almost  be  granted  that  we  can  have  jaws 
that  are  disproportionate  in  size.  For  instance,  this  is  the  only  explan- 
ation that  we  can  offer  for  the  condition  sometimes  found  in  which  the 
lower  jaw  is  so  large  that  the  molar  teeth  have  not  been  crowded  for- 
ward into  part  of  the  space  that  was  originally  occupied  by  the  deciduous 
molars,  and  permanent  interdental  spaces  remain  in  the  bicuspid  regions 
(Fig.  253).  We  know  of  no  growth  in  the  length  of  the  bone  that  can 
occur  at  this  site.  The  skull  illustrated  in  Fig.  254  shows  what  is  possi- 
bly an  atavistic  retraction. 

Disease  or  trauma  may  also  be  the  factor  that  determines  the  over- 
development or  underdevelopment  of  either  jaw.  If  from  any  cause 
there  is  a  nasal  obstruction  which  causes  mouth-breathing,  the  upper 
molar  teeth  are  deprived  of  the  support  of  the  tongue  and  the  lower 


Fig.    252. 

Fig.  251.  Greek  profile. — After  Farrar.  Here  we  have  a  high  forehead,  continuous 
with  a  long,  straight  nose,  a  short  upper  lip,  somewhat  retreating,  and  a  full  curved 
chin. 

Fig.   252.      Negro  head  showing  prominence  of  the  lower  part  of  the  face. 

molars.  In  children  this  allows  the  cheeks  to  press  the  teeth,  alveolar 
processes,  and  maxillary  bodies  inward.  As  the  upper  jaw  narrows, 
the  height  of  the  palate  arch  increases,  the  septum  buckles,  and  the 
width  of  the  nasal  fossae  is  lessened.  The  original  trouble  might  have 
been  lack  of  development  of  the  maxillae,  adenoids,  bony  occlusion  of 
the  posterior  nares,  or  any  other  obstruction.  But  no  matter  what,  the 
resulting  mouth-breathing  tends  to  still  further  lessen  the  size  of  the 
nasal  passages. 

The  normal  adult  relation  of  the  dental  arches  is  not  obtained  until 
the  bones  are  full-grown  and  the  jaws  are  separated  by  a  complete 
quota  of  teeth.  An  exception  may  possibly  be  made  of  the  third  mo- 
lars. The  development  of  the  face  as  a  whole  has  an  essential  bearing 
on  this  relationship.     For,  as  the  maxillae  grow  downward,  it  changes 


MALOCCLUSION  AND  IRREGULARITIES.  283 

the  plane  of  the  hard  palate  from  above  the  temporomaxillary  joint, 
as  found  in  infancy,  to  a  considerably  lower  level,  best  shown  in  an 
edentulous  skull  of  age.  The  body  of  the  mandible  is  carried  to  a  still 
lower  level  by  the  interposition  of  the  teeth  and  alveolar  processes. 


Fig.    253. 

Fig.  253.  Protrusion  of  the  lower  jaw,  due  partly  to  interdental  spaces  in  the 
bicuspid  region.  Part  of  the  protrusion  is  due  to  a  sliding  forward  of  the  body  as  a 
whole,  as  shown  by  the  relation  of  the  upper  and  lower  molars. 


Fig.   254. 

Fig.  254.  Retraction  of  the  lower  jaw.  Note  that  the  deformity  is  due  mostly  to 
a  shortening  in  the  ramus,  which  is  usually  the  case.  In  this  skull,  however,  all  of  the 
vertical  diameters — the  height  of  the  forehead,  the  height  of  the  orbit,  and  the  height 
of  the  ramus — are  short  in  comparison  with  the  transverse  diameters,  and  the  maxilla 
is  prognathic.  Yet,  when  considered  alone,  the  prominence  of  the  nasal  bones  and  the 
shape  of  the  cranium  would  place  the  skull  very  high  in  the  scale  of  development.  This 
we  take  to  be  a  plain  instance  of  atavism,  and  the  malocclusion  an  accident  dependent 
upon  this  atavism. 

The  ramus  of  the  lower  jaw  is  formed  to  compensate  for  this  change 
in  position  of  the  body.  Until  the  ramus  appears,  there  can  be  no  real 
angle.     Non-traumatic  malrelations  of  the  dental  arches,  or  a  portion 


28-4 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


of  them,  are  as  a  rule  early  determined,  dnd  if  not  controlled,  they  in- 
crease with  growth.  As  before  mentioned,  the  teeth,  properly  apposed 
to  each  other  in  normal  succession  with  concurrent  growth  of  the  bone, 
are  the  factors  that  establish  the  normal  jaw.  It  is  to  faulty  succession 
or  position  of  the  teeth  and  irregularities  of  bony  development  that 
most  of  these  deformities  of  the  bone  are  due.  Atavism,  trauma,  or 
disease  is  the  determining  factor. 

As  in  certain  cases  an  abnormal  angle  is  both  a  contributing  cause 
and  a  result,  a  study  of  this  angle  and  the  factors  which  control  it  is 
opportune.  During  the  period  of  complete  permanent  dentition  the 
angle  of  the  jaw  is,  as  a  rule,  about  100  degrees.  In  youth  and  ex- 
treme old  age  this  angle  is  greater.  From  youth  to  adolescence  these 
changes  are  accomplished  by  a  deposition  of  bone,  in  old  age  by  a  pro- 


Fig.  255.  Diagram  by  John  Hunter,  illustrating  the  normal  growth  of  the  mandi- 
ble. It  will  be  seen  that  the  bicuspid  teeth  occupy  less  space  than  did  the  deciduous 
molars  which  they  replace.  The  extra  space  is  used  partly  by  the  permanent  canines 
and  partly  by  the  first  permanent  molar  moving  forward.  If  the  teeth  are  not  crowded 
into  this  space,  bicuspid  internal  spaces  may  result.  In  the  younger  bones  it  will  be 
seen  that  there  is  quite  a  space  between  the  ramus  and  the  last  occluding  tooth. 


cess  of  absorption,  although  in  childhood  the  bone  may  be  bent  in  any 
part.  At  birth  the  body  of  the  mandible  is  straight  and  rests  squarely 
against  the  maxillae.  From  the  cutting  of  the  first  incisors  until  the 
third  molars  are  in  occlusion,  there  is  a  space,  posterior  to  the  occlud- 
ing teeth,  which  is  an  unsupported  arch,  upon  which  most  of  the  power 
of  the  internal  pterygoid  and  masseter  muscles  is  expended  (Fig.  255). 
The  body  of  the  lower  jaw  is  not  normally  called  upon  unaided  to  re- 
sist the  action  of  the  masticatory  muscles,  nor  is  it  capable  of  doing  so. 
These,  drawing  on  the  angle,  tend  to  cause  a  yielding  upward  in  the 
body  of  the  bone  in  the  space  between  the  teeth  and  the  ramus. 

Protrusion  of  the  Lower  Jaw. — The  bending  at  the  angle,  when 
the  body  is  unrestrained  by  proper  interlocking  of  the  teeth,  allows  the. 
angle  to  open  and  the  jaw  to  push  forward.     If,  during  this  period,  the 


MALOCCLUSION  AND  IRREGULARITIES. 


285 


inferior  incisors  are  not  firmly  locked  behind  the  superior,  we  have  the 
beginning  of  a  forward  protrusion,  which,  if  unresisted  artificially,  may 
result  in  the  undershot  jaw. 

Retraction  of  the  Lower  Jaw. — The  growth  of  the  mandible  is 
accomplished  by  the  deposit  of  bone  on  the  outer  surface  of  the  body 
and  at  the  epiphysis  of  the  condyle,  and  also  on  the  posterior  border 
and  tip  of  the  coronoid  process  and  on  the  posterior  border  of  the 
ramus,  with  an  accompanying  absorption  of  their  anterior  borders, 
which  brings  about  a  backward  march  of  the  ramus  (Fig.  255).  If 
the  lower  jaw  fails  to  develop  in  proportion  to  the  upper,  we  have  it, 
as  a  whole,  retracted.  Some  observations  have  led  us  to  believe  that 
a  short  ramus  is,  at  least  partially,  responsible  for  all  cases  of  retraction 
of  the  body.  Any  early  interference  with  the  movement  of  the  tem- 
poromandibular joint  is  always  accompanied  by  a  retraction  of  the 
lower  jaw. 


Pig.    256. 


Fig.    257. 


Pig.  256.  Open  bite  in  a  young  white  boy.  It  can  be  seen  tliat  the  separation  be- 
tween the  upper  and  lower  Incisors  is  due  to  the  erupting  first  permanent  molar. — Case 
of  Dr.  Lischer. 

Fig.  257.  Open  bite  in  a  young  negro  boy  showing  rachitic  malformation  of  the 
teeth.     Second  molars  are  In  contact. 

Open  Bite. — We  have  already  spoken  of  the  yielding  of  the  much- 
strained  jaw  body.  There  is  a  deformity,  which  appears  to  come  from 
the  yielding  of  an  abnormally  soft  bony  arch  between  the  occluding 
molars  and  the  ramus,  when  the  body  is  prevented  from  sliding  forward 
by  the  upper  incisors.  The  softened  arch  bows  upward  and  then  hard- 
ens, retaining  this  shape.  When  the  teeth  belonging  to  the  bowed 
section  attain  full  eruption,  they  are  on  a  plane  above  the  normal,  and, 
occluding  themselves,  cause  the  open  bite  in  the  anterior  portion  of  the 


286  SURGERY  OF  THE  MOUTH  AND  JAWS. 

jaw  (Figs.  25G  and  257).  Although  true  as  far  as  it  goes,  we  believe 
this  is  probably  but  a  partial  explanation  of  the  etiology.  These  are 
fairly  common  cases.  All  except  one  of  the  cases  of  this  kind  that  we 
have  observed  have  shown  evidence  of  early  rickets,  which  we  think 
is  the  ordinary   etiological   factor. 

In  most  of  the  cases  we  have  observed,  the  open  bite  seemed  to  be 
due  partly  to  a  bending  of  the  lower  jaw  in  front  of  the  second  molar 
and  partly  to  lack  of  development  of  the  alveolar  process  on  the  an- 
terior part  of  the  upper  jaw. 

Fracture,  malunion,  or  distortion  of  the  jaw  may  cause  open  bite. 
Inability  to  close  the  mouth  from  lack  of  muscular  force  is  a  thing 
almost  unheard  of.  After  an  excision  of  one  Gasserian  ganglion,  or 
cutting  of  its  posterior  root,  there  is  usually  paralysis  of  the  muscles 
of  mastication  of  that  side,  due  to  cutting  the  motor  root,  but  the  mus- 
cles of  the  other  side  carry  on  function  satisfactorily. 

Contracting  scars  from  burns  on  the  neck  and  chin  can  greatly  de- 
form the  developing  jaw-bone. 

ORTHODONTIA  IN  THE  TREATMENT  OF 
MALRELATIONS  OF  THE  JAWS. 

Before  the  twelfth  or  fourteenth  year  all  of  these  conditions  can  be 
more  or  less  perfectly  corrected  by  orthodontic  appliances;  the  success 
largely  depending  upon  the  age  at  which  the  treatment  is  begun — the 
earlier  the  better.  As  soon  as  any  limitation  of  motion  of  the  joint  is 
noticed,  systematic  forced  movements  should  be  practiced.  All  chil- 
dren who  have  suffered  injury  of  the  joint  or  have  had  profuse  sup- 
puration in  that  neighborhood  should  be  watched  carefully.  For  even 
when  the  limitation  finally  results  in  a  true  ankylosis,  it  develops  grad- 
ually and  often  goes  unnoticed  until  the  child  is  seen  to  be  forcing  food 
between  the  almost  closed  teeth". 

The  ability  of  the  orthodontist  to  change  the  position  of  the  teeth 
and  the  shape  of  the  bones  is  dependent  upon  the  same  factors  that 
permit  of  progressive  malocclusions.  In  the  growing  bones  abnormal 
pressure  in  any  direction  will  cause  a  tooth  to  move  its  position.  If 
this  pressure  is  gentle  and  continuous,  the  alveolar  bone  will  apparently 
move  with  it,  being  absorbed  and  redeposited  to  keep  pace  with  the 
tooth.  Some  of  the  force  is  transmitted  to  the  bones  themselves,  and 
in  the  very  young  the  shape  of  the  jaw-bones  will  be  influenced  by 
pressure  applied  to  the  crowns  of  the  teeth. 

INDICATIONS  FOR  SURGICAL  OPERATION. 

After  the  bones  have  hardened,  or  after  bony  ankylosis  has  oc- 
curred, appliances  will  accomplish  nothing,  and  when  the  deformity  is 


MALOCCLUSION  AND  IRREGULARITIES.  287 

pronounced,  these  cases  are  legitimate  and  proper  cases  for  surgical 
interference.  If  the  teeth  are  ever  lost,  it  is  impossible  to  make  satis- 
factory artificial  dentures  for  such  mouths. 

We  have  seen  both  disposition  and  nutrition  radically  influenced 
for  good,  and  in  the  case  of  w^omen,  the  resultant  good  cannot  be  over- 
estimated. We  would  advise  no  one  to  undertake  any  cases  with- 
out first  having  the  fullest  confidence  of  his  patient,  for  during  the  con- 
valescence trying  complications  might  arise  in  which  the  surgeon  will 
find  his  patience  and  his  resources  taxed  to  the  limit.  Operations  on 
cases  of  moderate  deformity  should  not  be  undertaken  lightly,  for  the 
unforeseen  accidents  of  surgery  can  here  put  the  operator  in  a  most 
unenviable  position.  It  is  real  surgical  work,  although  for  its  comple- 
tion orthodontia  is  indispensable ;  and  the  earlier  a  competent,  con- 
genial orthodontist  is  associated  in  the  case,  the  better  it  will  be  for 
both  the  surgeon  and  the  patient. 


CHAPTER  XXL 

TREATMENT  OF  DEFORMITIES  AND  MALRELATIONS 

OF  THE  JAWS. 

The  nasal  fossae  are  bounded  by  the  maxillary  bone  and  by  bones 
attached  to  the  maxillae ;  therefore  deformities  of  maxillary  bones  are 
apt  to  influence  the  size,  shape,  and  patency  of  the  nasal  fossae. 

DEFORMITIES  OF  THE  MAXILLAE:    OSSEOUS 
OBSTRUCTION  OF  THE  NARES. 

Nasal  obstruction  may  be  due  directly  to  deformity  or  to  lack  of  de- 
velopment of  the  maxillae.  If  to  bony  occlusion  of  the  posterior  nares 
or,  as  in  one  case  that  was  sent  to  us,  to  a  congenital  backward  dis- 
placement of  the  maxillae,  the  velum  and  mucoperiosteal  covering  of 
the  hard  palate  are  to  be  split  in  the  median  line.  The  bone,  including 
the  palate  process,  is  to  be  removed  until  ample  breathing  space  is  es- 
tablished. Then  the  palate  and  velum  are  to  be  immediately  sutured, 
as  in  an  operation  for  congenital  cleft  palate  (Figs.  153  to  162).  In 
clearing  such  a  bony  obstruction,  it  is  not  necessary  to  preserve  the  whole 
of  the  nasal  septum.  The  nasal  fossae  can  be  converted  into  one  cavity 
by  a  submucous  removal  of  the  bony  part  of  the  septum,  while  its  mu- 
cous covering  may  be  used  to  line  the  newly  made  part  of  the  passage. 

If  the  nasal  obstruction  is  due  simply  to  lack  of  size  of  the  nasal 
fossae  and  there  are  erupted  molar  teeth  in  both  maxillae,  then  the  treat- 
ment proposed  by  G.  V.  I.  Brown  might  be  indicated.  It  consists  of 
placing  a  jackscrew  across  the  mouth  from  one  upper  molar  to  another. 
As  the  screw  is  spread,  the  intermaxillary  suture  is  opened,  the  maxillae 
separate,  and  the  nasal  obstruction  is  relieved.  This  operation  can 
probably  be  successfully  done  before  the  tenth  or  twelfth  year,  and  the 
jackscrew  or  some  retaining  appliance  must  remain  in  place  until  the 
opened  suture  is  filled  with  bone,  which  requires  some  months.  This 
is,  of  course,  work  that  requires  the  technical  skill  of  a  dentist. 

RETRACTION  OF  THE  LOWER  JAW. 

Maxillary  prognathism  without  corresponding  projection  of  the 
lower  jaw  is  extremely  common.  When  it  is  sufficiently  pronounced  to 
be  a  deformity,  to  correct  it,  we  are  not  called  upon  to  attempt  to  raise 
the  profile  to  the  standard  set  by  the  Greek  sculptors,  which  would  be 
a  surgical  impossibility.     We  may,  however,  bring  forward  the  lower 

288 


DEFORMITIES  OF  THE  JAWS. 


289 


jaw  to  a  harmonious  outline,  thus  placing  it  within  the  limits  of  an 
accepted  type,  which  is  usually  a  possible  procedure. 

Artists  have  formulated  laws  of  correct  facial  outline  which  should 
somewhat  guide  us  in  this  work:  (1)  The  septolabial  angle  should 
be  ninety  degrees.  An  exception  to  this  is  the  case  of  the  overhang- 
ing Roman  nose,  where  it  may  be  greater.  (2)  The  lower  lip  should 
not  protrude  beyond  the  upper.  (3)  The  distances  between  the  hair- 
line and  the  root  of  the  nose,  between  the  root  of  the  nose  and  the  sub- 
nasal  angle,  and  between  the  latter  and  the  tip  of  the  chin  should  be 
about  equal.     None  of  these  rules,  however,  are  absolute. 


Fig.    258. 
Lischer. 


Retraction    of   the   mandible    corrected   by    orthodontic    appliances. — After 


Correction  by  Traction. — Before  twelve  or  fourteen  years  mod- 
erate retraction  of  the  mandible  can  be  corrected  by  orthodontic  appli- 
ances by  gradually  drawing  the  lower  teeth  and  jaw  forward  until  a 
new  occlusion  has  been  established  (Figs.  258  and  259).  This  is  apt 
to  leave  considerable  obliquity  of  the  chin,  which,  when  pronounced, 
can  be  treated  as  described  later  (page  29G). 

Correction  by  Surgical  Operation. — In  operating,  the  surgeon 
must  not  attempt  surgical  impossibilities  or  be  misled  by  false  issues. 
Occlusion,  normal  or  abnormal,  is  the  result  of  pressure  and  counter- 
pressure,  of  growth  and  apposition,  and  can  never  be  established  simply 


290 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


by  bone-cuts.  The  real  issues  ordinarily  at  stake  are  facial  outline 
(which  includes  both  the  profile  and  the  lateral  breadth)  and  the  ulti- 
mate occlusion,  while  immediate  occlusion  is  a  secondary  consideration. 
To  do  his  work  correctly,  it  is  necessary  that  the  surgeon  shall  have 
at  least  a  theoretical  knowledge  of  occlusion  and  of  the  scope  and  lim- 
itations of  orthodontic  operations. 

In  the  operations  to  be  described,  we  have  to  deal  with  an  upper 
cubical  jaw  and  a  lower  one  that  is  a  hoop  of  bone  capable  of  almost  any 
kind  of  adjustment;  and  it  is  upon  the  latter  that  our  efforts  must  be 
expended.  It  must  have  occurred  to  almost  every  thinking  observer 
that  it  would  be  easy  to  correct  the  open  bites  and  under-hung  jaws 
if  one  could  but  cut  through  the  bone  that  carried  the  nerve  and  blood 
supply  to  the  teeth.     The  ultimate  result  of  such  a  cut  has  been  the 


Fig.   259.     Retraction    of    tlie    mandible    rorrefted    by    orthodontic    appliance. — After 
Lischer. 

cause  of  much  contention  among  orthodontists  for  years.  A  fear  of 
necrosis  or  non-union  of  the  fragments  has  held  them  in  check, 
without  reason,  we  think.  L^iuinited  fracture  of  the  lower  jaw  is 
rare,  and  in  the  whole  of  the  "Surgeon  General's  Index"  there 
is  not  reported  a  single  case,  in  English,  German,  or  French  literature, 
of  necrosis  or  loss  of  teeth  from  sections  of  the  vertical  or  horizontal 
ramus.  Yet  this  is  a  recognized  procedure  for  ankylosis.  Esmarch 
recommends  the  removal  of  a  section  from  the  horizontal  ramus  for 
this  trouble,  because  of  the  liability  of  the  bones  reuniting  after  sim- 
ple section.  This  is  the  method  advised  in  the  standard  textbooks  of 
today.  We  do  not  think  that  we  need  to  concern  ourselves  with  the 
consequences  of  cutting  the  inferior  dental  nerve  and  artery.  Our  ex- 
perience, which  covers  quite  a  number  of  cases,  bears  out  this  conclusion. 


DEFORMITIES  OF  THE  JAWS. 


291 


In  retraction  of  the  lower  jaw  we  have  a  condition  in  which  the 
inferior  dental  arch,  as  a  whole,  bears  an  abnormal  relation  to  the  up- 
per; and  it  is  reasonable  in  correcting  it  to  move  it  as  a  whole.  This 
can  be  done  best  by  making  a  cut  through  the  vertical  ramus.  After 
the  cut  is  made,  the  jaw  is  moved  forward  to  the  position  desired.  Oc- 
clusion and  facial  outline  are  both  to  be  considered,  and  the  jaw  is  to 
be  steadied  in  place  by  inserting  soft  cement  between  the  grinding  sur- 
face of  the  teeth  and  fastening  the  lower  to  the  upper  with  wires.  Ar- 
tificial fixation  at  the  site  of  the  cut  is  unnecessary.  As  to  the  location 
and  direction  of  this  cut,  we  have  done  considerable  investigating,  but 


Fig.  260.  Transverse  section  of  the  face  at  the  level  of  the  occlusal  surfaces  of 
the  molars.  On  the  left  is  shown  the  wound  through  the  skm  and  fascia.  The  parotid 
gland  is  drawn  back  with  a  retractor,  and  the  wire  saw  is  seen  passing  around  the 
ramus  and  out  through  the  cheek.  Where  it  emerges,  the  skin  of  the  cheek  is  pro- 
tected by  passing  the  saw  through  a  thin  metal  tube.  On  the  right  side  are  indicated  : 
a,  parotid  gland ;  b,  temporomaxillary  vein ;  c,  internal  carotid  artery ;  d,  external 
carotid  artery ;  e,  ramus  of  the  jaw  containing  the  inferior  dental  nerve  and  vessels ;  f, 
internal  pterygoid  muscle  ;  g,  masseter  muscle  ;  h,  tonsil ;   i,  wall  of  the  pharynx. 

space  will  not  allow  us  to  do  more  than  state  our  conclusions.  This 
operation  can  be  done  above  the  entrance  of  the  inferior  dental  nerve 
and  vessels  into  the  canal,  thus  avoiding  their  section.  Here,  how- 
ever, one  may  be  crowded  for  space  and  run  the  risk  of  injuring  the 
parotid  gland,  large  vessels,  or  the  facial  nerves.  This  section  may 
be  made  in  the  line  of  the  grinding  surface  of  the  inferior  molars  (or, 
preferably  5  millimeters  above),  with  little  risk  of  injuring  any  im- 
portant structures  except  the  inferior  dental  nerve  and  artery.  In  cut- 
ting the  nerve  where  it  enters  the  canal,  which  is  at  about  this  point, 
it  has  the  best  opportunity  of  reuniting. 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


OPERATION  FOR  RETRACTION   OF  THE  LOWER  JAW. 

Cutting  the  Bone. — The  operation  is  done  in  this  manner:  An 
incision  2  centimeters  long-  is  made  through  the  skin  over  the  posterior 
border  of  the  mandible.  The  skin  is  drawn  forward,  and  the  parotid 
sheath  is  opened  at  the  anterior  border  of  the  gland,  which  latter  is 
drawn  backward  until  the  posterior  border  of  the  ramus  can  be  felt. 
A  large,  strong,  curved  needle  on  a  handle,  threaded  with  a  heavy  silk 


Fig.   261. 


Fig.    263. 


Fig.    262. 

Fig.  261.  Subcutaneous  section  of  the  ramus.  Showing  points  of  entrance  and 
exit  of  the  wire  saw. 

Fig.  262.  Needle  used  for  passing  a  carrier  around  the  ramus  of  the  jaw.  It  is 
important  that  the  curve  of  the  needle  extends  up  to  the  point.  If  the  point  end  of  the 
needle  is  somewhat  straight,  the  needle  is  very  apt  to  pierce  the  buccal  mucosa  and 
enter  the  mouth. 

Fig.  2G.3.  Dilator  used  for  stretching  the  muscles  and  also  for  stretching  bands 
about  the  joint.  It  is  made  from  a  uterine  dilator,  in  which  the  dilating  prongs  are 
shortened  and  then  covered  with  3  millimeters  of  solder.  Great  care  must  be  exercised 
in  using  this  instrument  to  avoid  avulsion  of  the  teeth  or  fracture  of  the  jaw. 


carrier,  is  now  passed  between  the  parotid  gland  and  the  masseter  mus- 
cle behind  the  ramus,  hugging  the  bone  closely.  It  passes  forward  be- 
tween the  ramus  and  the  internal  pterygoid  muscle  and  emerges  through 
the  cheek  without  penetrating  the  mucous  lining  of  the  mouth.  The 
diameter  of  the  curved  part  of  the  needle  should  be  a  little  greater  than 
the  width  of  the  ramus.  It  is  followed  by  a  Gigli  wire  saw  with  which 
the  bone  is  cut  through    (Fig.  2G1). 


DEFORMITIES  OF  THE  JAWS. 


293 


Hemorrhage  is  controlled  by  packing  the  space  with  sterile  or 
mildly  antiseptic  tape,  which  is  left  in  place  for  two  days.  In  this 
operation  the  parotid  gland  is  pushed  out  of  the  way,  as  is  also  the 
cervicofacial  division  of  the  facial  nerve,  which  lies  at  the  posterior 
border  of  the  jaw.  The  temporomaxillary  vein  is  also  avoided,  and 
the  external  carotid  lies  well  out  of  the  way.  These  anatomical  points 
were  verified  by  thirty  special  dissections  (Figs.  260  and  261). 

The  needle  used  is  full-curved.  The  curved  portion,  being  almost 
one  half  of  a  circle  of  4  centimeters  in  diameter,  must  extend  to  the 
point  in  order  to  round  the  anterior  border  of  the  ramus  without  pene- 


Fig.  264.  X-ray  showing  condition  of  the  ramus  some  time  after  section.  Notice 
the  obliquity  with  which  the  part  of  the  ramus  above  the  saw  cut  meets  the  lower  por- 
tion. Compare  with  Fig.  295,  Chap.  XXII,  which  shows  tlie  same  ramus  before  section. 
In  this  case  there  was  no  operation  performed  on  the  ankylosed  joint,  and  on  that  side 
there  is  only  a  fibrous  union  between  the  divided  parts  of  the  ramus.  Later  this  union 
became  so  close  that  it  was  necessary  to  excise  the  ankylosed  joint.  The  nail  and  wire 
at  the  chin  were  used  to  hold  a  piece  of  costal  cartilage  in  place. 


trating  the  mucosa.  The  point  is  so  formed  that  it  will  dissect  the 
soft  structures  from  the  inner  surface  of  the  bone  rather  than  penetrate 
them  (Fig.  262).  In  this  way  bleeding  is  avoided,  and  there  will  ordi- 
narily be  no  danger  of  penetrating  the  mouth.  To  prevent  damage  of 
the  skin,  after  the  saw  is  in  place,  a  short,  small  steel  tube  is  passed 
over  the  anterior  end  of  the  saw,  through  the  skin  and  down  to  the 
bone.  Posteriorly,  the  parotid  gland  is  held  back  with  a  small  retrac- 
tor. In  cutting  the  bone,  the  saw  is  held  as  straight  as  possible,  and 
the  operator  should  be  familiar  with  the  peculiarities  of  the  Gigli  saw 
(Figs.  260  and  261). 

This  operation  presents  three  distinct  problems:     (1)  the  cutting 


294 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


of  the  bone,  which  is  the  easiest  of  the  three;  (2)  the  placing  of  the 
jaw  in  its  new  position;  and  (3)  holding  it  there. 

Adjusting  the  Bone. — The  posterior  part  of  the  occlusal  plane 
of  the  molars  inclines  upward  and  backward.  On  account  of  this 
obliquity  the  body  of  the  lower  jaw  can  be  brought  forward  only  by 
lengthening  the  ramus ;  theoretically,  the  line  of  the  saw-cut  should  be 
slightly  downward  and  forward,  about  5  millimeters  lower  in  front  than 
behind,  so  as  to  allow  the  body  to  be  moved  downward  as  well  as 
forward  without  completely  separating  the  several  fragments.  As  a 
matter  of  fact,  however,  x-rays  show  that  the  fragments  of  the  ramus 
remain  in  contact  at  the  posterior  border  in  the  operations  we  have 
done,  and  it  is  very  difficult  to  exactly  gauge  the  positions  and  direc- 
tions of  the  cuts. 


Fig.    265. 


Fig.    266. 


Fig.  265.  Showing  deviation  of  the  chin,  which  may  occur  with  retraction  of  the 
jaw,  due  to  limitation  in  motion. 

Fig.  266.  Case  shown  in  Fig.  265,  after  operation.  The  chin  has  been  placed 
symmetrically. 

It  is  only  the  posterior  part  of  the  body  that  moves  downward,  and 
the  rotation  thus  produced  lessens  the  obliquity  of  the  plane  of  the 
chin,  which  is  a  very  distinct  advantage. 

In  order  to  lengthen  the  ramus,  it  is  necessary  to  stretch  the  mas- 
seter  and  internal  pter3'goid  muscles.  This  may  be  accomplished  by 
inserting  a  fulcrum,  such  as  a  piece  of  pine,  between  the  molars  on 
each  side  and  forcing  the  chin  upward.  (Another  plan  is  the  use  of 
the  dilator  shown  in  Fig.  3(i.T.)  We  have  even  found  it  necessary  to 
use  a  one-half-inch  piece  of  pine  board,  two  inches  wide  and  eighteen 
inches  long.  The  end  of  the  board  was  placed  back  between  the  last 
molars,  and  a  small  piece  of  wood  was  placed  transversely  between  the 
board  and  the  upper  bicuspids,  this  latter  being  done  to  prevent  injury 
to  the  incisor  teeth.     By  means  of  this  lever  the  muscles  were  cau- 


DEFORMITIES  OF  THE  JAWS. 


295 


tiously  stretched  until  the  jaw  could  be  brought  forward.  Even  after 
this  it  may  be  necessary  to  grind  or  remove  the  posterior  occluding 
molar  teeth,  and  if  this  is  necessary,  it  should  be  done  at  the  time  of 
the  operation.  As  the  bone  is  dragged  forward,  the  saw-cuts  gap  in 
front,  while  the  fragments  remain  in  contact  at  the  posterior  border. 
This  bone-gap  must  be  filled  with  granulations.  The  resulting  bone- 
scar  tends  to  contract  for  months  afterward,  and  unless  permanent  in- 
terlocking of  the  teeth  is  early  established  in  the  new  position,  some 
very  hard-earned  ground  will  be  lost    (Fig.   267). 

In  placing  the  body  of  the  jaw,  it  is  important  that  the  chin  is 
brought  to  the  midline.  Very  often  a  retracted  jaw  deviates  to  one 
side,  and  in  replacing  it  the  general  contour  of  the  face  is  a  better  guide 
than  the  teeth    (Figs.   265   and  266). 

Intraoral  Fixation. — As  for  means  of  fixation,  we  use  the  teeth. 


Fig.   267.      Showing  jaw  wired  in  its  new  position  after  section  of  the  ramus. 

having  never  had  satisfaction  from  any  external  adjuvant  that  we  have 
tried.  If  the  work  is  properly  done,  the  teeth  are  sufficient.  We  have 
used  all  kinds  of  bands,  but  have  found  that  the  finest  grade  of  soft 
iron  wire,  such  as  that  used  by  florists,  replaces  these  to  advantage. 
An  iron  wire  is  passed  around  the  crown  of  each  of  the  selected  teeth, 
fastened  by  two  full  twists.  Next,  the  ends  of  an  upper  and  a  lower 
wire  are  twisted  together,  maintaining  the  tension  while  making  the 
first  twist.  To  hold  the  jaw  forward,  the  upper  first  or  second  bicuspid 
is  wired  to  the  last  available  molar  in  the  lower  jaw  with  a  No.  22  or 
24  wire.  This  puts  the  pull  in  the  right  direction,  and  the  strain  is 
received  on  all  of  the  molars  in  both  jaws.  To  hold  the  chin  up,  the 
lower  canines  or  first  bicuspids  are  wired  to  the  teeth  directly  above 
with  a  No.  24  iron  wire,  or  preferably  two  bands  that  have  been  placed 
on  these  teeth  before  operation.  We  have  settled  on  this  iron  wire 
after  trying  almost  every  available  material;  for  it  is  strong,  does  not 


296  SURGERY  OF  THE  MOUTH  AND  JAWS. 

stretch,  is  very  pliable,  and  unless  nicked  by  sharp-toothed  instruments, 
will  stand  all  necessary  twisting.  Unless  there  are  a  number  of  inter- 
locking points  of  occlusion,  quick-setting  cement  should  be  placed  be- 
tween the  occlusal  surfaces  of  the  grinders;  for,  if  the  wires  are  exclu- 
sively depended  on,  the  retention  will  be  painful  and  unsatisfactory 
(Fig.  267). 

In  operating,  place  the  jaw  well  forward,  disregarding  the  immedi- 
ate occlusion  unless  it  interferes  with  your  ends ;  if  it  should,  grind  or 
remove  the  offending  teeth.  One  of  the  most  noticeable  features  of 
these  cases  is  the  obliquity  of  the  chin.  If  we  bring  the  incisors  into 
occlusion,  we  have  made  use  of  only  half  of  our  opportunity;  for,  be- 


Fig.   268.  Fig.    269. 

Pig.   268.      Showing  obliquity  of  chin  in  retraction  of  the  lower  jaw. 

Fig.  269.  Same  patient  as  shown  in  Fig.  268,  after  bringing  the  jaw  well  forward. 
The  obliquity  of  the  chin  is  seen  to  persist,  and  something  further  will  have  to  be  done 
to  render  the  result  Ideal.  It  was  the  result  here  shown  that  started  the  investigations 
that  led  to  the  transplantation  of  cartilage  to  correct  chin  obliquity. 

sides  the  receding  chin,  there  may  or  may  not  be  an  increased  subnasal 
angle  and  an  oblique  chin   (Figs.  2G8   and  269). 

Retraction  of  the  mandible  may  be  due  to  early  ankylosis  of  the 
joint,  which  it  always  seems  to  accompany.  In  this  case  we  have 
found  it  advantageous  to  do  the  operation  for  ankylosis,  described  in 
Chap.  XXII,  and  at  the  same  time  bringing  the  jaw  forward  after  cut- 
ting the  ramus  on  the  sound  side.  We  have  had  to  resort  to  the  opera- 
tion for  ankylosis  after  bringing  the  jaw  forward. 

OBLIQUITY  OF  THE  CHIN. 

If,  as  will  often  be  the  case  after  an  orthodontic  or  a  bone-cutting 
operation  for  a  receding  jaw,  the  obliquity  of  the  chin  is  so  pronounced 
as  to  detract  materially  from  the  result,  it  may  be  improved  by  either 
injecting  paraffin  into  the  chin  or  inserting  a  piece  of  cartilage  or  rib. 


DEFORMITIES  OF  THE  JAWS. 


297 


We  studied  and  thought  over  the  subject  for  three  years  before  we  at- 
tempted to  cofrect  this  chin  obHquity. 

ParaiBn"  Injection. — Until  rather  recently,  we  had  no  experience 
with  the  injection  of  paraffin ;  a  continuously  increasing  observation  of 
poor  results  from  attempts  to  correct  nasal  deformities  made  us  ex- 
tremely wary  of  the  procedure.  Of  late,  however,  we  have  taken  up 
the  use  of  paraffin  and  have  been  forced  to  the  conclusion  that  its  in- 
jection has  a  limited  place  in  surgery,  and  if  the  operation  is  properly 
done,  is  as  little  likely  to  be  followed  by  objectionable  results  as  some 
other  surgical  operations.     We  think  it  might  be  the  proper  procedure 


Fig.  270.  Girl,  twenty  years  of  age.  Complete  bony  ankylosis  of  left  side,  result- 
ing from  periarticular  suppuration,  following  scarlatina  at  five  years.  Lower  teeth  had 
been  removed  to  allow  for  a  feeding  space. 

in  certain  cases  of  chin  obliquity  to  place  the  paraffin  deep  in  the  tis- 
sues just  in  front  of  the  periosteum.  The  materials  required  are :  soft 
paraffin,  melting  at  about  120"  F.  (there  is  paraffin  on  the  market 
labeled  to  melt  at  110"  F.,  but  experiment  will  show  that  it  takes  a 
temperature  of  about  ten  degrees  higher  to  melt  it)  ;  and  a  regular 
paraffin  syringe,  in  which  the  piston  is  threaded  and  travels  only  by  a 
screw.  In  children  the  operation  had  best  be  done  under  ether,  but  in 
adults  a  local  anesthetic  can  be  used.  A  1  per  cent  solution  of  novo- 
cain in  normal  saline,  to  which,  after  boiling  and  cooling,  is  added  1 
part  of  adrenalin  chlorid  to  each  150,000  parts  of  the  novocain  solution, 
is  to  be  injected  into  the  tissues.     After  waiting  for  twenty  minutes, 


298 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


for  the  excess  of  solution  to  be  absorbed,  the  paraffin  injection  may 
be  made.  Before  attempting  to  make  a  paraffin  injection,  the  surgeon 
should  practice  with  his  assistant  until  the  paraffin  can  be  handled 
without  a  hitch.  The  sterile  paraffin  is  melted  and  drawn  into  a  hot 
sterile  syringe,  all  air  being  expelled.  Air  in  the  syringe  will  cause  the 
paraffin  to  shoot  out  in  jets,  and  the  quantity  injected  will  not  be  under 
the  operator's  control.  The  syringe  is  then  placed  in  a  basin  of  sterile 
water  at  a  temperature  of  125°  F.  The  water  and  the  syringe  are  al- 
lowed to  cool  until  the  paraffin  can  be  forced  out  of  the  needle  in  a 
plastic  thread.     This  is  the  form  in  which  the  paraffin  should  enter  the 


Fig.   271.      Case   shown    in   Fig.    270,    after    bringing   body    of   the    jaw    forward    and 
transplanting  costal  cartilage  into  chin. 


tissues.  Blocking  in  the  needle  may  be  overcome  by  dipping  the  nee- 
dle in  hot  water  or  by  applying  a  hot  wet  sponge  to  it. 

In  making  the  injection,  and  in  practicing  beforehand,  the  assistant 
should  handle  the  syringe  and  make  the  injection — the  surgeon  insert- 
ing the  needle,  directing  the  amount,  and  controlling  the  paraffin  in  the 
tissues  by  finger  pressure.  The  paraffin  hardens  quickly,  and  it  is 
easier  to  make  several  injections  than  to  remove  it  when  in  excess  or 
misplaced.  Judging  from  several  instances  in  which  we  have  dissected 
out  misplaced  paraffin  from  the  eyelids  and  around  the  nose,  the  par- 
affin becomes  incorporated  in  a  growth  of  firm  fibrous  tissue,  the  shape 
of  which  cannot  be  changed  by  pressure. 

Transplantation  of  Bone  or  Cartilage. — To  fill  out  the  chin  with 


DEFORMITIES  OF  THE  JAWS. 


299 


bone  or  cartilage,  an  incision  is  made  under  the  chin,  and  all  of  the 
tissues  excluding  the  periosteum  are  reflected  from  the  mental  portion 
of  the  mandible.  Bleeding  should  be  controlled  by  pressure.  Next, 
the  seventh  or  eighth  costal  cartilage  is  exposed,  and  a  section  removed, 
including  its  perichondrium.  This  should  be  done  without  wounding 
the  pleura  or  the  intercostal  vessels,  though  we  have  several  times 
wounded  the  pleura  in  a  dog  without  any  apparent  evil  consequences. 
The  cartilage  is  picked  up  with  toothed  forceps  and  trimmed  with  a 
cutting  bone  forceps;  the  finger  with  or  without  gloves  should  not  be 


Fig.   272.      Case  shown  in  Fig.   270.     Profile  before  operation. 

put  into  either  wound.  As  soon  as  each  skin  wound  is  made,  the  knife 
that  cuts  through  the  skin  should  be  discarded,  and  the  skin  excluded 
from  the  operating  field  by  attaching  sterile  cloths  to  the  cut  edges 
with  tenaculum  forceps  or  safety  pins.  The  cartilage  can  be  fastened 
to  the  bone  with  one  or  two  wires  or  nails.  The  bone  and  cartilage 
having  been  drilled,  the  wound  is  closed  without  drainage  by  deep 
through-and-through  silkworm  gut  sutures.  If  suppuration  should  oc- 
cur, neither  the  sutures  nor  the  cartilage  are  to  be  removed  unless  the 
infection  be  of  a  virulent  character.  We  have  had  two  pieces  of  carti- 
lage and  one  piece  of  the  tibia  stay  in  place  and  unite  to  the  soft  tis- 
sues by  its  perichondrial  or  periosteal  surface  when  there  was  suppura- 


300 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


tion  occurring  in  its  deep  surface.     In  one  of  the  cartilage  cases,  an  in- 
jection of  Beck's  bismuth  paste  stopped  the  suppuration. 

The  transplantation  of  cartilage  or  bone  is  not  difficult.  The  peri- 
chondrium must  be  preserved  (Figs.  270  to  273).  In  one  dog  Dr. 
Coughlin  and  the  writer  transplanted  thirteen  pieces  without  a  single 
one  suppurating. 

PROTRUSION  OF  THE  LOWER  JAW. 

Protrusion  of  the  lower  jaw  may  be  from  overgrowth,  from  sliding 
forward,  or  from  a  combination  of  these. 


Fig.  273.  Case  shown  in  Fig.  270,  after  operations.  The  scar  on  cheek  is  from 
suppuration  at  the  site  of  wound  for  cutting  ramus.  The  dark  spot  under  chin  is  wound 
through  which  the  cartilage  was  inserted.  Neither  this  nor  the  cheek  wound  had  en- 
tirely healed  at  the  time  the  photograph  was  taken.  Later  this  scar  became  almost  in- 
visible. 

The  lower  jaw  may  protrude  a  considerable  distance  beyond  the 
upper.  When  the  protrusion  is  marked,  especially  if  there  are  inter- 
dental spaces  in  the  bicuspid  region,  the  lingual  inclination  of  the  in- 
cisors is  extreme  (Fig.  2.");)).  This  is  due  to  the  pressure  of  the  orbi- 
cularis   oris    muscle. 

Correction  by  Traction. — To  correct  this  condition,  different 
means  must  be  adopted.  If  seen  early,  before  the  twelfth  year,  in 
many  cases  the  jaw  can  be  forced  back  to  its  proper  position  by  a  chin 
and  head  cap  connected  by  elastics  and  worn  for  several  hours  each 
day.  after  the  plan  suggested  by  Angle.     That  this  will  be  successful  in 


DEFORMITIES  OF  THE  JAWS. 


301 


every  case,  we  are  not  sure.  If  seen  after  the  bone  growth  is  com- 
pleted, a  different  means  of  correction  must  be  adopted,  which  is  the 
removal  of  a  piece  of  the  jaw-bone  on  either  side  (Figs.  274  to  276). 

Correction  by  Surgical  Operation. — Where  the  lower  jaw  as  a 
whole  occupies  a  forward  position,  there  will  be  also  lateral  protrusion, 
for  two  reasons:  (1)  The  broader  posterior  part  of  the  lower  jaw  is 
brought  opposite  the  narrow  anterior  portion  of  the  upper;  and   (2) 


^HHR"  .'*^  ^  -  \,      ^^1 

j^H 

^■^       N  '       '                                          ^ 

^^^^1 

^^^Hl                         '^^^"^v 

^H 

■Kli^u 

M 

^^^^^^^^^ 

^ 

J 

Fig.    274. 


Fit 


Fig.    276. 

Fig.  274.  Protrusion  of  lower  jaw  In  man,  27  years  of  age.  Lower  jaw  is  ab- 
normally large,  and  upper  jaw  abnormally  small.  When  the  mouth  closed,  no  tooth  in 
the  lower  jaw  touched  any  tooth  in  the  upper  jaw. 

Fig.   275.     Same  case  as  shown  in  the  preceding  figure. 

Fig.  276.  Case  shown  in  the  preceding  two  figures  after  operation.  On  the  right 
side  a  section  of  the  jaw-bone  was  excised  behind  the  first  molar  tooth. 


when  this  occurs,  the  impact  of  the  jaw  is  taken,  not  on  the  buccal 
cusps  of  the  lower  molars,  as  is  normal  (Fig.  249),  but  on  a  part  nearer 
the  lingual  cusps.  This  tends  to  rotate  the  lower  molars  lingually, 
which  is  accompanied  by  an  outward  rotation  of  the  lower  border  of 
the  bone.  Thus  we  have  a  real  spreading  at  the  lower  part  of  the 
body.  This  lateral  protrusion  must  also  be  corrected  or  compensation 
made. 


302  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Sections  of  bone  of  the  proper  size  are  removed,  and  the  fragments 
brought  together.  The  cuts  are  ilkistrated  in  Figs.  279  and  280,  by  the 
hues  (aa).  The  sections  (dd)  are  removed,  then  the  fragments  (cbc), 
shown  in  dotted  hnes,  are  moved  in  and  back  to  form  the  new 
arch  (c',  b'',  cO-  The  lateral  fragments  rotate  on  an  axis  correspond- 
ing, not  to  the  last  molar  tooth,  but  to  the  temporomandibular  articu- 
lation (oy).  Now,  as  the  distance  from  the  cut  to  the  last  molar 
(xx)  is  about  one  half  that  from  the  cut  to  the  axis  of  rotation  (xy), 
the  anterior  end  of  the  fragment  will  move  in  twice  as  far  as  does  the 
last  molar,  which  is  about  in  proportion  to  the  usual  displacement  of  the 


Fig.  277.  Protrusion  of  the  lower  jaw.  Correction  by  orthodontic  appliance. — ■ 
After  Lischer. 

two  points.     By  this  operation  both  the  lateral  and  the  forward  pro- 
trusions are  corrected. 

In  determining  the  location  of  the  cuts  and  their  directions,  plaster 
models  and  x-ray  should  be  used.  Still,  here,  as  everywhere  else,  the 
eye  and  the  finger  of  the  operator  must  be  the  surgeon's  most  useful 
guides  and  instruments  of  precision.  While  one  can  bring  forward  a 
retreating  chin  with  every  assurance  of  improving  the  facial  outline, 
in  setting  back  a  protruding  chin  so  that  the  lower  incisors  will  be  in 
normal  occlusion  with  the  upper,  one  might  destroy  the  one  strong 
feature  in  an  otherwise  weak  face. 


DEFORMITIES  OF  THE  JAWS. 


303 


Often  protrusion  of  the  lower  jaw  is  accompanied  by  an  abnormally 
small  upper  jaw;  therefore  the  chin  should  be  brought  back  only  far 
enough  to  be  in  harmony  with  the  other  features,  leaving  it  to  the 
orthodontist  to  bring  forward  the  upper  incisors  if  necessary,  but  the 
orthodontist  should  be  in  consultation  in  the  case  from  the  first.  In- 
deed, in  some  cases  it  would  be  of  considerable  advantage  to  have  the 
upper  jaw  expanded  and  the  upper  incisors  and  canines  brought  for- 
ward before  the  operation  on  the  lower  jaw. 

The  contraction  of  the  upper  jaw  is  probably  due  to  the  fact  that 
the  tongue  finds  an  abnormal  amount  of  room  within  the  lower  dental 
arch,  which  allows  the  upper  arch  to  contract  or  fail  of  full  develop- 
ment. If  the  size  of  the  lower  arch  is  suddenly  contracted,  the  tongue 
will  be  deprived  of  some  of  its  accustomed  intraoral  space  and  must  be 


Pig.  278.  Protrusion  of  tlie  lower  jaw  corrected  by  ortlaodontic  appliance.- — After 
Li.scher. 

forced  back  into  the  oral  pharynx.  We  have  never  seen  more  than  a 
temporary  respiratory  embarrassment  from  this,  but  it  is  a  point  to  be 
borne  in  mind. 

In  operating  for  protrusion  of  the  lower  jaw,  the  bone  may  be  cut 
in  the  ramus  or  the  body.  In  first  considering  this  operation,  we  dis- 
missed the  ramus  for  the  reason  that  in  the  case  in  hand  much  of  the 
protrusion  was  due  to  overgrowth  of  the  body,  and  we  feared  that,  if 
we  cut  the  ramus  and  forced  the  body  back,  the  space  behind  the  angle 
might  be  crowded  when  the  mouth  was  opened. 

Dr.  W.  Wayne  Babcock,  of  Philadelphia,  reports  two  cases  which 
he  corrected  by  operation  upon  the  ramus.  From  the  illustrations, 
however,  we  believe  that  in  his  cases  the  deformity  was  due  wholly  to 
a  sliding  forward  of  the  body  and  not  to  an  overgrowth  of  the  bone. 


30-4 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


If  our  conception  of  the  pathology  is  correct,  it  is  perfectly  reasonable 
to  correct  such  cases  by  sliding  the  body  back  into  place.  Dr.  Bab- 
cock  was  led  to  adopt  this  procedure  for  fear  that,  if  the  anterior  at- 
tachment of  the  tongue  was  moved  back,  there  might  be  respiratory 
embarrassment ;  for,  if  this  followed  the  operation  on  the  ramus,  it  could 
be  corrected  by  drawing  the  jaw  forward. 

Tn  operating  upon  the  body,  the  bone  may  be  cut  submucously  with- 
out extending  the  incision  into  the  mouth,  in  which  case  the  wound 
should  remain  sterile.  The  open  operation,  in  which  the  bone  and  its 
coverings  are  sawed  through  right  into  the  mouth,  is  not  fraught  with 
the  dangers  that  some  commentators  on  this  operation  have  conjured 
up.     It  is  a  fact,  known  to  all  of  any  clinical  experience,  that  nearly 


Fig.    279 


Fig.    280. 


Fig.  279.  Abnormally  long  jaw  with  interdental  spaces  in  the  bicuspid  region. 
Showing  position  of  cuts  for  correction. 

Fig.  280.  Reconstructed  jaw,  showing  how  both  forward  and  lateral  protrusions  are 
corrected  by  removing  bone  sections.  The  dotted  lines  indicate  the  jaw-bone  shown  in 
the  preceding  figure. 

all  fractures  of  the  body  of  the  jaw-bone  are  open  fractures  and  that, 
unless  there  is  splintering  or  comininution,  these  open  fractures  unite 
about  as  quickly  as  do  closed  fractures.  Even  when  there  is  considera- 
ble suppuration,  healing  and  union  usually  follow  quickly  after  inferior 
drainage  is  established  and  the  pieces  of  dead  bone  are  removed. 

While  the  subperiosteal  operation  has  much  to  commend  it,  not  all 
of  the  points  are  in  its  favor.  The  sawing  can  be  more  accurately  done 
with  a  straight  than  with  a  wire  saw,  and  none  of  the  remaining  bone 
is  deprived  of  its  periosteum.  Should  there,  during  the  subperiosteal 
operation,  be  established  through  accident  a  communication  between 
the  wound  and  the  mouth,  necrosis  of  the  bone  might  occur;  a  thing 
most  improbable  when  the  periosteum  is  left  intact  on  the  remaining 
bone  and  free  drainage  is  provided. 


DEFORMITIES  OF  THE  JAWS.  305 

As  before  stated,  the  site  of  the  bone-cnts,  the  size  and  shape  of  the 
sections  to  be  i-emoved,  and  the  means  of  retaining  the  newly  con- 
structed jaw  are  determined  before  the  operation.  We  think  the  site 
of  election  is  at  the  second  bicuspids,  but  one  may  be  deterred  from 
sacrificing  these  teeth  by  the  presence  of  other  natural  or  acquired  in- 
terdental spaces.  We  once  removed  a  section  at  the  site  of  a  missing 
second  molar  on  one  side.  If  the  submucous  operation  is  to  be  done, 
the  teeth  are  to  be  removed  at  least  four  weeks  before  the  operation, 
but  if  it  is  to  be  an  open  operation,  the  teeth  may  be  removed  at  the 
same  time.     In  operating  on  the  ramus,  no  teeth  need  to  be  removed. 

TRANSMUCOPERIOSTEAL  OPERATION  FOR 
PROTRUSION  OF  THE  LOWER  JAW. 

The  mouth  having  been  properly  prepared,  the  shoulders  are  raised, 
and  the  head  drawn  back. 

Fixing  the  Jaw. — In  order  to  render  the  jaw  rigid,  a  pine  block 
is  inserted  between  the  molar  teeth,  on  one  side,  behind  the  site  of  the 
proposed  bone  section.     The  jaws  are  closed  firmly  on  the  block,  and 


Fig.   281.      Adjustable   double-bladed   saw,   which   is   very   useful   when  the   case   per- 
mits of  making  parallel  cuts  through  the  bone. 


held  there  by  wires  passing  between  the  molars.  This  will  fix  the 
lower  jaw  securely;  this  fixation  cannot  be  as  completely  obtained  by 
means  of  a  mouth  gag. 

Cutting  the  Bone. — Corresponding  to  the  site  of  the  bone  which 
is  to  be  removed,  the  skin  lying  under  the  border  of  the  jaw  is  drawn 
upward,  and  a  cut  2  or  2^/^  centimeters  is  made  parallel  with  this  bor- 
der. This  will  render  the  scar  inconspicuous  when  the  operation  is 
complete.  The  incision  extends  through  the  skin,  fascia,  and  platysma. 
The  tissues  are  dissected  from  the  outer  surface  of  the  jaw-bone,  but 
without  on  any  account  injuring  or  even  exposing  the  periosteum.  The 
dissection  is  continued  upward  until  the  mouth  is  opened  through  the 
buccoalveolar  cul-de-sac,  the  mucous  covering  of  the  gum  being  left 
intact. 

Before  inserting  the  saw-blade,  the  exact  position  of  the  first  saw- 
cut  is  determined,  and  a  flat  piece  of  metal  may  be  inserted  into  the 
wound  and  turned  on  edge  so  as  to  rest  against  the  bone  just  to  the 
outside  of  and  parallel  with  the  first  cut.     This  will  serve  as  both  a 


306  SURGERY  OF  THE  MOUTH  AND  JAWS. 

guide  to  the  saw  and  a  protection  from  the  soft  tissues  which  would  de- 
flect the  blade  from  its  proposed  course.  The  handle  of  a  knife  or  the 
blade  of  another  saw  can  be  used  for  this  purpose ;  but  if  the  edge  that 
rests  on  the  bone  is  toothed,  it  will  not  slip,  and  if  the  protector  is  fixed 
on  a  right-angled  handle,  it  can  be  used  with  greater  ease.  No  matter 
what  kind  of  a  saw  is  used,  for  obvious  reasons  the  bone  should  not 
be  cut  entirely  through  in  any  place  until  the  fixation  holes  are  drilled 
near  the  lower  border  and  all  of  the  other  saw-cuts  are  at  least  three 
fourths  of  the  way  through.  We  have  a  mechanical  saw,  very  narrow 
and  probe-pointed  (a  nasal  saw  modified),  run  by  an  engine  and  cable, 
that  cuts  very  rapidly;  but  a  sharp  narrow-bladed  metacarpal  saw  will 
suffice,  and  is  probably  safer.  We  use  also  an  adjustable  probe-pointed 
double-bladed  saw,  which  is  ideal  for  making  parallel  cuts  (Fig.  281). 

SUBMUCOPERIOSTEAL  OPERATION  FOR  PROTRUSION 
OF  THE  LOWER  JAW. 

If  the  interdental  spaces  are  not  sufficiently  large,  the  teeth  from 
the  sites  of  the  proposed  bone  sections  must  be  removed  at  least  one 
month  before  the  operation  so  that  the  gum  tissues  will  be  entirely 
healed.  It  is  even  better  to  wait  until  considerable  absorption  of  the 
alveolar  process  has  taken  place. 

The  mouth  is  prepared  for  operation  as  usual.  The  exact  site  of 
the  piece  of  bone  to  be  removed  should  be  marked  on  the  skin  with  a 
pencil  or  a  knife  scratch.  This  will  correspond  to  the  center  of  the 
skin  incision.  After  the  skin  of  the  face  and  neck  is  prepared,  a 
sterile  cloth  or  towel  is  sewed  across  the  face  from  ear  to  ear  on  a  line 
running  between  the  mouth  and  the  chin.  This  towel  is  turned  up- 
ward over  the  ether  mask  and  prevents  contamination  from  coughing 
or  vomiting.  It  is  not  necessary  to  fix  the  jaw,  as  it  can  be  held  up 
with  the  fingers  of  an  assistant. 

Cutting  of  the  Bone. — An  incision  3  or  4  centimeters  long  is 
made  along  the  under  border  of  the  jaw  down  to  the  periosteum.  The 
soft  tissues  are  dissected  from  the  periosteum  half  way  up  the  inner 
and  outer  surfaces  of  the  body  of  the  jaw;  from  here  up  to  within  a 
short  distance  of  the  necks  of  the  teeth,  the  dissection  is  subperi- 
osteal. If  the  necks  of  the  teeth  should  be  exposed,  there  would  be 
a  communication  between  the  wound  and  mouth.  It  is  easier  to  make 
the  whole  dissection  subperiosteally,  but  the  vitality  of  the  bone  is 
better  assured  when  the  exposed  ends  are  not  entirely  deprived  of 
this  source  of  nutrition.  At  the  site  of  the  interdental  spaces  a  curved, 
blunt  needle  is  passed  over  the  alveolar  border  of  the  jaw,  hugging 
the  bone  closely;  on  no  account  must  this  be  allowed  to  penetrate  into 


DEFORMITIES  OF  THE  JAWS. 


307 


the  mouth.     It  is  followed  by  a  silk  or  linen  carrier  which  in  turn 
draws  a  Gigli  saw  into  place^    (Fig'-  2'S2). 

The  ring  on  one  end  of  the  Gigli  saw  is  to  be  cut  ofif,  and  the  end 
bent  into  a  sharp  hook;  this  takes  less  room  than  the  ring  and  is  less 
liable  to  injure  the  mucoperiosteum  of  the  gum.  The  eye  of  the  op- 
erator is  his  only  guide  in  making  the  cuts.  Before  making  the  cuts, 
the  bone  should  be  drilled  for  wires,  and  no  saw-cut  should  be  com- 
pleted until  all  of  the  others  in  both  sides  are  almost  entirely  through ; 
otherwise  one  will  be  dealing  with  fragments  that  are  difficult  to  con- 
trol. For  this  reason  it  is  better  to  use  four  saws.  It  is  better  to  re- 
move too  little  than  too  much  bone;  for,  though  the  jaw-bone  is  ex- 
tremely hard,  it  can  be  rongeured  away  with  a  good  instrument  or  a 


Fig.  282.  Submucous  resection  of  the  lower  jaw.  Coronal  section  through  the  body 
of  the  jaw  and  the  surrounding  tissues,  a,  tissues  of  the  cheek  ;  b,  mucoperiosteum  of 
the  gum  raised  from  the  body  of  the  jaw ;  c,  body  of  the  jaw,  covered  with  periosteum 
on  its  lower  part ;  d,  submaxillary  tissues  ;  n,  curved  needle  passed  over  the  body  of  the 
jaw ;  r,  retractors  holding  back  the  cheek  and  submaxillary  tissues  ;  s,  wire  saw,  with 
ring  replaced  by  a  sharp  bend,  attached  to  the  needle  by  a  silk  carrier. 


coarse  bone  bur.  While  doing  this,  each  fragment  can  be  held  with  a 
pair  of  sharp-toothed  lion  forceps  that  will  grasp  the  bone  but  will  not 
tear  its  coverings. 

If  only  the  alveolar  portions  of  the  bone  are  left  in  contact  with  a 
V-shaped  space  left  open  below,  the  chin  fragment  of  the  jaw  may 
later  become  tilted  downward,  as  the  alveolar  bone  will  not  form  firm 
union. 

Adjusting  the  Bone. — The  bone  sections  having  been  removed, 
the   new  arch   is   formed  by  wiring   the   remaining    fragments   with 

^The  instrument  common  on  the  market  is  an  imported  Gigli  saw  made  with 
two  running  spiral  threads  on  a  round  wire,  which  is  of  such  inferior  quality  that 
at  one  time  we  about  abandoned  the  use  of  the  Gigli  saw.  Of  late,  however,  we 
have  procured  some  saws  which  are  made  of  a  twisted  square  wire,  with  four 
threads.  This  saw  cuts  for  a  much  longer  time  without  clogging,  and  the  quality 
of  the  steel  seems  to  be  better. 


308  SURGERY  OF  THE  MOUTH  AND  JAWS. 

silver  wire,  which  was  put  through  the  holes  drilled  before  the  saw- 
cuts  were  made.  The  final  twisting  of  these  wires  is  not  done  until 
the  intraoral  fixation  is  made. 

Intraoral  Fixation. — The  means  of  splinting  the  fragments  is 
important.  HuUihan,  in  1850,  for  a  case  in  which  he  had  resected  and 
replaced  the  alveolus,  devised  a  continuous  metal  splint,  cemented  over 
all  the  teeth  in  the  lower  jaw  (Fig.  57).  We  first  tried  wiring  the 
bones,  and  also  the  lower  jaw  to  the  upper.  In  commenting  on  a  case 
of  this  kind  on  which  we  had  operated.  Dr.  Angle  suggested  a  metal 
splint  made  in  three  sections,  which  is  to  be  cemented  over  the  teeth 
before  the  operation.  The  portions  of  each  side  to  be  removed  were 
not  to  be  covered  by  the  splint,  and  the  adjacent  ends  of  the  splint  were 
to  serve  as  guides  in  the  sawing.     When  the  bone  is  removed,  the  ends 


Fig.   283.  Fig.   284. 

Fig.  283.  Lateral  view  of  Angle  splint,  showing  flanges  drilled  for  bolts,  and  also 
bicuspid  teeth  that  were  removed  at  operation. 

Fig.  284.  Angle  splint  after  operation,  lateral  view.  To  allow  for  inaccuracies,  the 
distance  between  the  flanges  was  made  larger  than  the  section  of  bone  to  be  removed. 
After  operation  the  space  between  the  plates  was  fllled  with  a  piece  of  lead  pJate,  beaten 
and  cut  to  the  proper  shape. 

of  the  three  pieces  of  splint  are  fastened  together.  We  have  not  found 
it  practical  to  make  the  splint  serve  as  a  saw  guide,  but  Figs.  383  and 
284  show  a  modification  of  Angle's  idea,  made  for  us  by  Dr.  J.  A. 
Brown,  which  worked  satisfactorily.  The  use  of  such  a  splint 
allows  the  mouth  to  open.  We  would  not  dispense  with  the  lower 
fixation  in  this  operation.  Proper  fixation  here  consists  of  fastening 
the  cut  bones  with  silver  wire  or  with  chromicized  catgut  at  their  lower 
borders,  and  for  the  upper  fixation  using  the  Angle  splint,  or  wire. 
In  wiring,  the  teeth  adjacent  to  the  cuts  should  not  be  used.  It  will 
be  much  better  to  have  bands,  carrying  rings  on  their  buccal  surfaces, 
attached  to  teeth  just  beyond  those  bordering  on  the  cuts.  That  is, 
if  the  bone  section  is  removed  from  the  site  of  the  second  bicuspid, 
the  canine  and  second  molar  will  carry  the  bands.    Bands  are  placed 


DEFORMITIES  OF  THE  JAWS. 


309 


on  upper  teeth  that  will  correspond  to  the  bands  below  after  the  jaw 
is  cut.  The  fixation  is  made  by  passing  a  wire  between  the  two  lower 
bands  and  between  each  of  the  lower  bands  and  the  one  above  (Fig. 
285).  Here  solidity  will  be  gained  by  placing  cement  or  softened  gutta- 
percha at  proper  places  between  the  occlusal  surfaces,  but  space  must 
be  allowed  for  the  taking  of  liquid  food.  We  consider  this  the  best 
plan  of  fixation. 

The  intraoral  fixation  and  the  lower  fixation  should  be  done  to- 
gether so  that  neither  one  will  throw  the  other  entirely  out  of  balance, 
as  might  be  the  case  if  the  cuts  are  badly  made.  The  teeth  can  be 
moved  later,  and  it  is  not  necessary  to  have  absolutely  accurate  bony 
contact. 

The  bone  wires  are  twisted,  bent  down,  and  cut  at  the  lower  border 


Fig.    286. 


Fig.  285.  Fixation  of  the  jaw  by  wires  and  bands,  after  removing  a  section  from 
the  body.      (The  lower  wire  should  be  shown,  bent  downward.) 

Fig.  286.  Reconstruction  of  an  open  bite  in  a  boy  16  years  of  age,  due  possibly  to 
the  very  early  crumbling  away  of  the  crowns  of  the  deciduous  molars  which  had  oc- 
curred.     Showing  correction  by  simple  section  of  the  body  of  the  jaw  on  each  side. 

of  the  jaw  so  that  they  can  be  found  if  it  is  necessary  later  to  remove 
them. 

The  deep  part  of  the  wound  is  closed  with  interrupted  No.  00  tan- 
nated  gut,  and  the  skin  is  closed  with  interrupted  silkworm  gut.  A 
small  spirally  split  tube  or  fold  of  rubber  dam  is  to  be  led  to  the  bone 
cut  and  sutured  into  the  skin. 

If  the  wound  heals  primarily,  the  sutures  may  be  removed  in  four 
days.  If  the  wound  suppurates,  unless  there  is  a  virulent  infection, 
some  of  the  sutures  should  remain  until  there  is  no  danger  of  the 
wound  gaping. 

BABCOCK'S  OPERATION  FOR  PROTRUSION  OF  THE 

LOWER  JAW. 

If  the  protrusion  is  due  entirely  to  a  sliding  forward  of  the  body 
and  there  are  no  abnormal  interdental  spaces  or  supernumerary  teeth, 


310  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  means  adopted  by  Babcock  is  surely  the  simpler  and  proper  oper- 
ation. Dr.  Babcock  exposed  the  ramus  and  cut  it  with  a  chisel,  but  we 
think  the  method  of  cutting  the  ramus,  described  under  Retraction  of 
the  Jaw,  has  several  advantages  over  the  open  operation.  The  jaw  is  to 
be  fixed  as  after  the  operation  of  bringing  the  body  forward,  but  the 
posterior  wires  must  be  so  applied  that  they  will  hold  the  body  back- 
ward, in  place  of  forward.  The  teeth  should  be  made  to  interlock  so 
that  the  lower  jaw  cannot  again  push  forward  before  the  permanent 
callus  completely  fixes  the  bone. 

OPEN  BITE. 

Correction  by  Traction. — A  slight  open  bite  in  a  child  under 
twelve  years  may  be  corrected  by  the  orthodontist.  In  older  persons, 
the  anterior  teeth  may  be  lengthened  by  porcelain  crowns. 

Correction  by  Surgical  Operation. — If  it  is  decided  that  an  op- 
eration on  the  jaw-bone  is  necessary,  a  study  of  plaster  reproductions 
of  the  dentures  will  reveal  the  character  of  the  operation  indicated. 

OPERATION  FOR  OPEN  BITE. 

In  some  cases  all  that  will  be  required  is  a  simple  section  of  the 
jaw  on  both  sides,  in  front  of  the  first  tooth  that  occludes  with  those 
above.  Then  the  anterior  fragment  can  be  moved  up  to  occlusion 
(Fig.  286).  In  others  it  will  be  necessary  to  remove  a  V-shaped  sec- 
tion from  the  bone  on  each  side,  just  in  front  of  the  first  occluding 
tooth.  The  apex  of  this  V-shaped  section  is  at  the  lower  border  of  the 
jaw,  and  usually  a  tooth  must  be  extracted  from  the  site  of  the  section 
on  each  side  (Fig.  287).  The  bone-cutting  can  be  done  from  within 
the  mouth  with  a  Gigli  saw  or  cross-cut  fissure  bur,  but  we  believe  it 
better  surgery  to  operate  from  below  as  in  the  open  operation  for  pro- 
trusion of  the  lower  jaw.  The  method  shown  in  Fig.  288  has  the  ad- 
vantage of  not  shortening  the  lower  jaw. 

As  before  cited,  the  open  bite  is  partially  due  to  deformity  of  the 
upper  jaw,  and  the  surgeon  must  not  expect  to  be  able  to  entirely  cor- 
rect it  in  all  cases  by  an  operation  on  the  lower  jaw.  A  better  result 
will  come  from  restoring  the  lower  jaw  to  its  proper  form  and  cor- 
recting the  remaining  open  bite,  either  by  bringing  down  the  upper  in- 
cisors with  an  orthodontic  appliance  or  by  extending  them  with  porce- 
lain crowns. 

Fixation. — The  fixation  is  to  be  made  as  after  a  section  of  the 
body  of  the  mandible  for  protrusion.  If  the  teeth  in  the  chin  frag- 
ment are  very  poor  so  as  to  afford  an  insufficient  anchorage,  the  mouth 
may  be  dressed  0])en  by  means  of  a  splint  ])reviously  made  on  recon- 
structed plaster  dentures.     This  will  prevent  the  chin  fragment  from 


DEFORMITIES  OF  THE  JAWS. 


311 


being  pulled  down  by  the  digastric  and  geniohyoid  muscles.  If  the 
upper  teeth  will  afford  good  anchorage,  two  silver  wires  may  be  passed 
entirely  around  the  chin  fragment  and  anchored  to  the  teeth  above 
(Fig.  38). 

ATYPICAL  DEFORMITIES. 

In  the  classification  of  jaw  deformities  here  given,  we  do  not  wish 
to  convey  the  impression  that  we  have  systematized  the  whole  subject, 
but  rather,  for  convenience,  we  have  made  this  grouping  from  the 
cases  which  have  come  under  our  observation. 

There  are  other  deformities  which  will  have  to  be  considered  indi- 
vidually, although   on  the  general  lines  which  have  been  laid  down 


Fig.  287.  Open  bite  of  an  extreme  type  in  a  young  man,  showing  how  correction 
might  be  made  by  a  V-shaped  excision.  This  would  have  the  disadvantage  of  shortening 
the  jaw  considerably,  as  shown  in  the  reconstructed  jaw  indicated  by  dotted  lines.  TTie 
operation,  shown  in  Fig.  288,  was  done  in  this  case. 

Fig.  288.  Showing  operation  by  S-shaped  bone-cut,  that  lengthens  the  jawbone 
and  gives  a  better  closure  of  the  mouth.  The  silver  splints  at  the  site  of  the  bone-cut 
are  absolutely  necessary,  and  increase  the  risk  of  sepsis.  The  bone  spaces  will  fill  in 
satisfactorily,  but  the  transverse  part  of  the  "S"  cut  must  be  in  hard  bone. 

here.  Contraction  of  scars  from  burns  on  the  neck  and  chin  can 
greatly  affect  the  shape  of  the  lower  jaw.  Although  the  title  of  the 
chapter  does  not  include  them,  deformities  arising  from  unreduced 
unilateral  or  bilateral  dislocations,  malunion  of  fractures,  etc.,  are  ger- 
mane to  the  subject.     They  are  to  be  corrected  on  these  same  lines. 

PREOPERATIVE  CONSIDERATIONS. 

The  instruments  should  always  include  tooth  forceps  and  means  for 
grinding  the  teeth.  If  the  surgeon  is  not  familiar  with  the  use  of 
these,  there  should  also  be  present  someone  who  knows  how  to  use 
them.  The  surgeon  should  be  thoroughly  familiar  with  the  strength 
and  twisting  endurance  of  the  wire  he  is  using. 


312  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Before  operating,  the  patient  should  be  in  the  best  possible  condi- 
tion; the  air-passages  should  be  free,  and  foci  of  suppuration  in  any 
part  of  the  body  should  be  rigidly  excluded. 

The  surgeon,  by  prolonged  study,  should  have  made  himself  thor- 
oughly familiar  with  the  anatomical  conditions  which  he  will  treat. 

AFTER-TREATMENT. 

After  the  operation  there  will  always  be  sufficient  space  between 
the  teeth  to  take  liquid  and,  in  most  cases,  semifluid  food.  Nutrition 
and  hygiene  should  be  kept  at  the  top  notch.  Rigid  mouth  asepsis  be- 
fore, during,  and  after  the  operation  is  the  best  preventive  of  sore  and 
painful  mouths. 


CHAPTER  XXII. 

DISEASES  OF  THE  TEMPOROMANDIBULAR  JOINT- 
LIMITED  MOVEMENT  OE  THE  JAW. 

The  temporomandibular  joint  is  a  diathroidal  joint  more  or  less  sub- 
ject to  the  same  diseases  as  are  other  joints  of  the  same  character. 

DISEASES  OF  THE  TEMPOROMANDIBULAR  JOINT. 

It  is  particularly  liable  to  be  affected  by  suppurative  processes  in  its 
immediate  neighborhood.  We  have  also  seen  cases  in  which  the  joint 
has  been  destroyed,  probably  as  the  result  of  gonorrheal  arthritis,  me- 
tastatic septic  arthritis,  or  arthritis  following  scarlatina.  We  have  seen 
destruction  of  the  joint  apparently  following  simple  injury.  Tubercu- 
lous arthritis  of  the  joint  is  probably  very  rare.  The  joint  is  sometimes 
affected  along  with  others  in  hypertrophic  arthritis,  but  the  most  com- 
mon affection  of  which  people  complain,  for  which  they  seldom  seek 
relief,  is  "cracking"  of  the  jaw.  This  may  be  acute  or  chronic.  It 
seems  to  be  due  to  a  laxity  of  the  ligaments  which  allows  the  intra- 
articular fibrocartilage  to  become  caught  by  the  condyle,  causing  either 
a  cracking  sound  or  a  distinct  momentary  locking.  Sometimes  in  the 
more  acute  cases  it  is  accompanied  by  quite  disagreeable  sensations. 

Treatment. — For  any  disease  that  demands  an  operation  within 
tJie  joint  capsule,  the  plan  of  approach  that  is  detailed  under  the  Treat- 
ment of  Ankylosis  would  be  appropriate. 

It  is  somewhat  difficult  to  distinguish  between  an  intra-  or  periartic- 
ular suppuration,  and  usually  the  pus  is  liberated  only  when  it  begins 
to  point.  The  joint  could  be  opened  by  a  transverse  incision  along  the 
lower  border  of  the  zygoma,  from  its  middle  back  to  the  tragus.  With 
care,  by  drawing  back  the  tissues  with  retractors,  the  auriculotemporal 
nerve  and  the  temporal  artery  can  be  avoided. 

The  most  effective  treatment  of  acute  joint  troubles  is  rest,  with  or 
without  the  application  of  heat  or  cold,  which  treatment  is  easily 
adapted  to  this  joint. 

In  an  acute  painful  condition  the  patient  will  hold  the  jaw  fairly 
quiet,  but  in  many  subacute  processes  help  can  be  gained  by  artificially 
limiting  the  movements  of  the  jaw. 

As  the  mouth  opens,  the  condyle  of  the  jaw  glides  downward  over 
quite  a  large  arc.  By  limiting  the  amount  that  the  mouth  can  be 
opened,  the  condyle  can  be  confined  to  the  posterior  part  of  the  fossa ; 

313 


314  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  damage  to  an  inflamed  joint  can  in  this  way  be  lessened,  and  the 
ligaments  given  a  better  chance  to  recover.  A  head-and-chin  bandage 
will  partially  control  the  motion  of  the  jaw,  but  a  more  acceptable  plan 
is  to  place  a  band  on  an  upper  and  a  corresponding  lower  bicuspid 
tooth,  each  band  to  have  on  its  outer  side  a  small  ring  through  which 
is  threaded  a  silk  ligature  which  will  limit  the  amount  of  opening. 

At  first  the  jaw  may  be  allowed  to  open  5  or  10  millimeters,  and 
later,  as  the  condition  improves,  the  excursion  can  be  increased.  The 
ligatures  break  frequently,  but  the  patient  can  be  taught  to  have  some 
one  at  home  replace  them.  Three  weeks  is  the  longest  that  we  have 
ever  continued  this  treatment  for  anything  but  a  chronic  dislocation, 
and  have  thought  that  quite  as  much  was  gained  from  the  habit  of  not 
opening  the  mouth  wide  as  from  the  actual  treatment.  If  this  treat- 
ment is  adopted  for  some  very  active  inflammation  that  might  be  fol- 
lowed by  adhesions,  the  means  for  overcoming  adhesions  should  be 
instituted  as  soon  as  the  acute  process  has  subsided. 

HYSTERICAL  CLOSURE  OF  THE  JAWS. 

Inability  to  open  the  mouth  may  be  a  hysterical  phenomenon,  which 
is  most  common  in  young  women.  The  clinical  history  of  the  case 
and  the  lack  of  a  definite  lesion  are  the  bases  of  the  diagnosis.  The 
patient  is  of  a  "nervous"  temperament  and  usually  gives  a  history  of 
having  had  similar  attacks  before,  usually  recovering  rather  suddenly. 
The  attacks  are,  as  a  rule,  associated  with  some  mental  strain  or 
worry,  and  while  the  attack  lasts,  which  may  be  for  weeks,  the  amount 
of  opening  varies.  Here,  as  with  every  other  supposed  hysterical  mani- 
festation, the  diagnosis  should  be  made  only  after  very  careful  con- 
sideration. 

The  treatment  consists  in  general  treatment  of  the  patient,  encour- 
agement, and  the  assurance  that  the  condition  will  disappear. 

LIMITATION  DUE  TO  REFLEX  IRRITATION. 

An  inflammatory  process  in  the  posterior  part  of  the  floor  of  the 
mouth,  the  cheeks,  pharynx,  or  of  the  external  auditory  canal  may 
prevent  the  patient  from  opening  the  mouth  on  account  of  the  pain 
it  causes,  but  the  limitation  may  be  entirely  involuntary  with  no  pain, 
due  to  reflex  irritation  of  an  intraoral  lesion.  Disease  of  a  lower  tooth 
is  the  most  common  cause  of  reflex  spasm  of  the  muscles  of  mastication, 
but  an  upper  tooth  or  an  ulcer  on  the  tongue  may  cause  the  same  thing. 
When  the  source  of  irritation  is  removed,  the  spasm  is  almost  at  once 
relieved.  Irritation  from  the  third  molars  is  a  common  source  of 
such  a  spasm.  The  attacks  may  recur  several  times  with  varying 
intensity  before  the  source  of  the  irritation  is  discovered.     This  point 


DISEASES  OF  TEMPOROMANDIBULAR  JOINT.  315 

should  be  remembered  in  making  a  diagnosis  of  hysterical  spasms. 
There  may  be 'one  or  several  muscles  involved  in  the  spasm.  If  the 
cause  is  not  evident,  the  vitality  of  the  teeth  should  be  tested,  and  any 
treatment  that  is  indicated  should  be  instituted. 

Prinz's  electrical  reaction  is  the  most  delicate  test  of  the  condition 
of  the  pulps,  while  the  x-ray  might  locate  pulp-stones,  enlargement  in 
the  roots,  or  chronic  alveolar  abscess. 

The  limitation  may  be  directly  mechanical,  due  to  inflammatory 
masses,  new  growths,  or  malunion  of  fractures,  and  it  should  not  be 
forgotten  that  tonic  spasm  of  the  jaw  muscles  is  an  early  symptom 
of  tetanus. 

LIMITATION  OF  MOVEMENTS  FOLLOWING  WAR 

INJURIES. 

While  extensive  gunshot  injuries  in  the  region  of  the  ramus  of  the 
mandible  may  cause  limitation  of  motion  due  to  the  formation  of 
cicatrices,  true  joint  ankylosis   from  this  cause   is  rare. 

The  commonest  variety  (four-fifths  of  all  cases)  of  constriction  of 
the  jaws  following  war  wounds,  according  to  Imbert  and  ReaP,  is 
a  muscular  contraction  (hypermyotonia)  characterized  by  the  fact 
that  it  is  produced  the  instant  the  wound  is  received  and  may  follow 
an   insignificant   lesion. 

The  treatment  of  trismus  due  to  muscular  contracture  consists 
in  stretching  the  jaws  by  means  of  special  instruments  introduced 
between  the  teeth  for  this  purpose.  The  resistance  to  the  muscles  is 
usually  easily  overcome  and  may  frequently  be  accomplished  without 
an  anesthetic.  A  simple  instrument  (Fig.  289),  suggested  by  Herpin-, 
is  made  of  two  pieces  of  hardwood,  30  cm.  in  length,  fastened  to- 
gether by  means  of  a  simple  hinge,  which  permits  of  an  opening  of 
the  jaws  of  the  instrument  to  an  extent  of  5  cm.  The  handles  serve 
as  levers,  and  throughout  half  of  their  length  beginning  at  the  hinge, 
have  a  series  of  notches  cut  in  them.  These  notches  accommodate 
rings  of  rubber  which  regulate  the  opening  of  the  jaws  of  the  instru- 
ment, more  or  less  great  and  energetic,  according  to  the  distance  of 
application  of  the  elastic  traction  from  the  hinge.  The  jaws  of  the 
instrument,  on  their  internal  and  external  surfaces,  are  covered  with 
a  plate  of  German  silver,  and  on  this  is  stamped  a  semicircular  ridge 
in  order  to  allow  the  retention  of  the  stretcher  between  the  teeth 
of  the   two   jaws. 

The  instrument  is  introduced  closed  between  the  teeth  and  opened 
with  a  moderate  but  sustained  pressure.  During  the  opening,  the 
patient  is   encouraged   to   talk   if   possible,   by  asking  him   questions. 


iRevue  Neurol,  Par..  1916,  xxiii,  912. 
2Presse  Medicale,  May  8,  1916. 


316 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


After  the  first  treatment,  there  are  two  daily  seances  of  half  an  hour 
each  with  the  automatic  mouth  opener.  Between  treatments  the  mouth 
is  kept  open  with  wood  blocks  placed  between  the  teeth.  Later,  the 
patient  is  encouraged  to  use  the  jaws  as  much  as  possible  by  chewing 
gum. 


Fig.    289.      Wooden    dilator    for    stretcliing    scar    bands. — After    Herpin. 

Colyer^  describes  an  instrument  (Fig.  290)  for  gradual  opening 
of  the  jaws  which  has  the  advantage  of  more  evenly  distributing  the 
force  over  several  teeth.     The  apparatus  consists  of  two  curved  metal 


Fig.    290.      Apparatus  for  gradual  separation  of  jaws  in  trismus. — After  Colyer. 

plates  covering  the  occlusal  surfaces  of  the  teeth,  the  plates  being 
united  at  each  end  by  parallel  screws  supplied  with  nuts.  The  mouth 
is  screwed  open  at  night  and  the  gag  remains  in  until  morning. 


3Colyer:      .Jour.  li.  A.  iVI.  C,  191G,  597. 


DISEASES  OF  TEMPOROMANDIBULAR  JOINT.  317 

LIMITATIONS  DUE  TO  SCAR  BANDS  OR  ANKYLOSIS. 

The  conditions  described  above,  including  inflammatory  obstruction, 
are  transitory.  If  the  Hmitation  is  due  to  scar  bands  or  an  ankylosis, 
the  condition  will  be  permanent  until  some  successful  means  of  cor- 
recting it  is  adopted.  The  scar  bands  that  bind  the  jaws  together  may 
be  situated  anywhere  between  the  symphysis  and  the  joint.  An  anky- 
losis may  be  true,  in  which  case  one  or  both  joints  are  replaced  by  a 
bony  union ;  or  it  may  be  false,  due  simply  to  intra-  or  periarticular  scar 
bands  and  adhesions.  If  an  ankylosis  or  a  very  great  limitation  has 
occurred  early,  there  will  be  retraction  of  the  chin  due  to  lack  of  devel- 
opment of  the  mandible  (Figs.  208,  272,  291,  303  and  3(M). 


Fig.  291.  Showing  child  at  five  years,  who,  probably  as  the  result  of  injury,  had 
a  double  fibroosseous  ankylosis  existing  for  two  years.  A  resection  was  made  of  both 
joints,  which  gave  a  free  opening  of  2  centimeters.  No  attempt  was  made  to  brinp  for- 
ward the  body  of  the  jaw,  for,  on  account  of  the  age  of  the  child,  we  thought  the  jaw 
would  develop   after  an  opening  was  established. 

Ankylosis,  either  true  or  false,  may  result  from  injury  or  disease. 
In  young  persons  the  disease  is  usually  an  articular  or  periarticular 
suppurative  process  and  may  follow  any  of  the  acute  infectious  dis- 
eases, especially  scarlet  fever.  It  may  be  due  to  scars  resulting  from 
extensive  intraoral  ulceration.  In  many  of  these  cases  the  ulceration 
is  supposed  to  have  been  the  result  of  salivation,  but  from  the  appear- 
ance and  extent  of  those  we  have  observed,  we  are  more  inclined  to 
credit  them  to  noma.  In  any  case  in  which  there  has  been  an  injury 
to  the  joint,  a  periarticular  suppuration,  or  deep  intraoral  ulceration, 
the  movement  of  the  jaw  should  be  watched  for  months  afterward. 


318  SURGERY  OF  THE  ^lOUTH  AND  JAWS. 

Any  limitation  of  motion  that  persists  or  increases  after  the  acute 
process  subsides  should  be  treated  by  gentle  forced  movement.  In 
many  cases  a  piece  of  rubber  inserted  between  the  jaws  and  allowed 
to  remain  for  a  short  while  several  times  a  day  will  stretch  adhesions 
and  newly  formed  scars.  An  ordinary  rubber  bottle-stopper  is  very 
useful  for  this ;  another  plan  is  the  insertion,  between  the  molars,  of 
sections  of  a  large  laminaria  uterine  tent,  which  swells  by  absorption 
of  saliva  but  which  is  soft  enough  not  to  injure  the  teeth.  If  this 
means  is  adopted,  the  surgeon  should  assure  himself  that  the  tent  has 
not  been  impregnated  with  any  antiseptic.  If  the  scars  are  firm,  but 
if  on  examination  it  is  found  that  the  jaw  can  be  made  to  move  a 
perceptible  amount  more  than  the  patient  ordinarily  moves  it,  dilatation 
with  rubber  or  laminaria  tents  should  be  tried  as  long  as  anything  is 
being  gained.     This  forced  dilatation  should  not  be  brutal  in  its  severity, 


Fig.  292.  Showing  an  apparatus,  which  was  made  for  us  by  J.  A.  Brown,  for  a 
gentleman  who  had  a  strong  fibrous  ankylosis  of  long  standing,  and  whose  remaining 
teeth  were  loose.  It  consists  of  an  upper  and  lower  vulcanite  plate  which  fit  evenly 
over  the  gums  and  teeth.  Between  these  is  placed  a  small  thick-walled  rubber  bag  at- 
tached to  an  air-pump  by  a  tube.  Dilatation  is  accomplished  by  forcing  air  into  the 
bulb.  This  is  in  use  at  present,  and  is  accomplishing  a  satisfactory  result.  The  bulb 
is  held  in  place  by  a  strip  of  elastic  dam.  The  bulb  must  be  made  very  thick  and 
strong,  and  it  must  not  touch  the  tongue  or  palate. 

for  what  cannot  be  gained  by  patient  and  gentle  means,  as  a  rule  can- 
not be  gained  by  excessive  force. 

In  a  few  selected  cases  in  which  the  adhesions  are  intra-  or  peri- 
articular, wide  excursion  can  be  accomplished  by  forceful  dilatation 
under  an  anesthetic,  but  this  must  be  done  with  great  care;  for  teeth 
may  be  pushed  clear  out  of  their  sockets,  or  the  jaw  may  be  broken. 
The  latter  accident  may  occur  with  little  force  in  a  delicately  formed 
jaw  where  there  is  a  deep  socket  of  an  unerupted  third  molar.  Both  of 
these  accidents  have  occurred  with  us. 

Where  there  are  no  teeth  or  where  the  teeth  are  loose  in  their 
sockets,  some  other  plan  of  dilatation  will  have  to  be  adopted  (Fig. 
292). 

OPERATIVE  TREATMENT  OF  ORAL  SCAR  BANDS. 

Narrow  bands  may  be  cut  or  dissected  out,  and  the  buccal  mucous 
membrane  can  be  stitched  in  such  a  way  as  to  fill  the  gap  that  is  left; 
but  no  permanent  good  can  be  expected  from  simply  cutting  dense  adhe- 


DISEASES  OF  TEMPOROMANDIBULAR  JOINT. 


319 


sions,  which  leave  a  broad,  raw  surface  to  granulate.  As  the  wound 
heals,  it  will  contract,  and  the  condition  will  be  not  in  the  least  improved. 
The  introduction  of  rings  into  these  scars  before  cutting  them,  and 
other  such  tricks,  are  but  poor  substitutes  for  a  proper  operation  that 
recognizes  and  eliminates  the  cause  of  the  fixation.  If,  at  the  site 
of  the  attachment  of  the  scars  to  the  jaw  bones,  the  buccoalveolar 
fornix  is  preserved  above  and  below — that  is,  if,  as  is  seldom  the  case, 
the  scar  is  attached  high  up  on  the  maxilla  and  low  down  near  the 
lower  border  of  the  mandible — the  operation  proposed  by  Le  Dentu 
will  be  more  or  less  effective. 

It  consists  in  a  submucous  cutting  of  the  scar  band  above  and 
below  at  its  maxillary  and  mandibular  attachments.  The  mouth  is 
then  opened  and  held  open  until  the  cut  ends  of  the  scar  band  find 
new  attachments  lower  down  on  the  maxillae  and  higher  up  on  the 


Pig.  293.  Showing  the  inability  to  open  the  mouth  after  extensive  removal  of  an 
intrabuecal  carcinoma  with  a  cautery  because  of  the  scar  on  the  inner  surface  of  the 
ramus.  The  buccal  scar  resulting  from  the  cauterization  was  removed,  and  the  cheek 
lined  with  skin  without  result.  B  shows  the  opening  obtained  by  removing  a  section  of 
the   ramus   under    local    anesthesia. 

body  of  the  mandible.  We  have  never  performed  the  operation, 
because  we  have  never  seen  what  we  thought  an  appropriate  case. 
As  a  rule,  the  fornix  is  abolished,  the  band  being  attached  at  the  gum 
margin,  and  too  often,  on  removing  or  releasing  the  scar,  it  is  found 
that  changes  have  occurred  in  or  near  the  joint  that  must  be  remedied 
before  the  mouth  can  be  opened. 

For  all  cases  of  closure  of  the  mouth  by  intraoral  scar  bands,  wc 
prefer  the  following  procedure,  because,  being  based  on  good  surgical 
principles,  when  properly  done,  it  will  disappoint  neither  the  patient  nor 
the  operator. 

OPERATION  BY  FLAP  TRANSPLANTATION. 

The  scar,  or  nearly  all  of  it,  is  excised,  and  the  soft  tissues  dis- 
sected from  the  periosteum  of  the  jaws,  above  and  below,  to  restore 


320 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  natural  depth  of  the  cul-de-sacs.  Scar  that  extends  through  the 
cheek  to  the  face,  especially  at  the  corner  of  the  mouth,  is  treated  at 
the  same  time.  To  satisfactorily  remove  some  intrabuccal  scars,  it 
may  be  necessary  to  turn  up  the  cheek  in  the  form  of  a  flap  by  an 
incision  running  from  the  angle  of  the  mouth  to  the  border  of  the 
jaw  and  then  back  along  this  border,  as  in  operating  for  carcinom.a 
of  the  inner  surface  of  the  cheek.  This  will  be  followed  by  paralysis 
of  the  depressor  anguli  oris  muscle  of  this  side,  which  does  not  cause 
a  very  noticeable  deformity. 

If  one  is  certain  that  after  removing  the  scar  the  nutrition  of  the 
lower  lip  will  be  preserved,  the  lip  and  chin  can  be  split  in  the  median 


Fig.   294.      X-ray  showing  condyle,   coronoid   process,   and   ramus   in   a  normal  joint. 

line,  and  half  of  it  turned  aside  with  the  cheek.  We  think  its  nutrition 
may  be  considered  safe  if  the  coronary  artery  is  intact.  In  removing 
the  scar  from  the  inner  surface  of  the  cheek,  the  opening  of  Stenson's 
duct  should  be  identified  and  preserved.  The  next  step  is  to  turn  a 
flap  from  the  neck  (p.  253;  Figs.  112,  220,  and  222)  and  suture  it  to 
the  raw  surface  in  the  cheek  instead  of  across  the  palate.  Especial 
care  should  be  taken  to  stitch  the  edge  of  the  flap  high  up  on  the 
outer  surface  of  the  maxilla  so  as  to  be  certain  to  restore  the  cul-de- 
sac.  Later,  scar  contraction  of  the  uncovered  granulating  surface 
of  the  bone  will  pull  down  the  border  of  the  flap  and  lessen  the 
depth  of  the  newly  made  fornix.  If  the  raw  surface  entirely  sur- 
rounds the  opening  of  the  parotid  duct,  a  small  hole  is  to  be  made  in 


DISEASES  OF  TEMPOROMANDIBULAR  JOINT.  321 

the  flap,  and  the  edges  sutured  around  the  mouth  of  the  duct.  If  the 
opening  of  the  duct  cannot  be  identified,  drainage  through  the  flap 
must  be  provided.  Otherwise  healing  will  be  complicated  by  having 
the  space  between  the  flap  and  the  cheek  fill  first  with  saliva  and  then 
with  pus  and  saliva. 

The  epithelial  lining  of  the  cheek  having  been  restored,  any  de- 
formity or  deficiency  of  the  cheeks  or  lips  is  repaired  by  flaps  that 
were  planned  before  the  operation. 

After  ten  days,  if  extensive  primary  union  of  the  transplanted  flap 
has  occurred,  after  a  longer  period  if  one  is  not  certain  that  the  new 


Pig.  295.     X-ray  showing  true  bony  anliylosis  of  the  joint. 

blood  supply  is  ample,  the  base  of  the  flap  is  cut,  and  the  defect  in  the 
neck  repaired.  If,  after  the  scar  has  been  removed  and  the  resulting 
defect  filled  by  a  well-nourished  flap  of  skin  and  subcutaneous  fascia, 
the  mouth  can  be  opened  a  desirable  distance,  the  surgeon  may  feel 
satisfied  that  the  contraction  will  not  return.  The  transplanted  skin 
soon  takes  on  an  appearance  somewhat  resembling  the  mucous  mem- 
brane, and  in  our  experience  has  never  shown  any  irritation  in  its 
new  location.  If,  after  excising  the  scar,  it  is  found  that  the  mouth 
cannot  be  opened  sufficiently,  an  operation  on  the  joint  will  be  required. 
The  patient  should  be  cognizant  of  this  possibility  before  the  first 


323  SURGERY  OF  THE  MOUTH  AND  JAWS. 

operation  is  performed.  An  operation  that  restores  movement  at  the 
natural  joint  site  seems  to  us  better  surgery  than  an  excision  of  a 
section  of  the  ramus  or  the  body.  The  one  to  be  described,  besides 
restoring  the  function  to  a  greater  mass  of  the  muscles  of  mastication, 
is  followed  by  no  visible  scar. 

It  consists  in  freeing  the  ramus  from  the  base  of  the  skull  and 
inserting  between  the  bones  a  flap  of  subcutaneous  fat-bearing  fascia 

Before  operation  it  should,  if  possible,  be  determined  whether  the 
joint  damage  is  one-sided  or  bilateral.  This  may  usually,  but  not 
always,  be  ascertained  by  good  negatives  (Figs.  294  and  295).  It 
has  been  our  observation  that,  in  an  unilateral  close  fibrous  ankylosis, 
in  attempting  to  open  the  mouth,  the  chin  deviates  to  the  ankylosed 
side.  This  is  due  to  a  slight  twisting  motion  at  the  damaged  joint, 
while  the  uninjured  condyle  travels  on  an  arc  with  the  other  one  as 
a  center. 

OPERATIONS  FOR  ANKYLOSIS  OF  THE  JAW. 

The  hair  is  shaved  to  a  point  5  centimeters  above  the  level  of  the 
ear  and  back  to  the  level  of  its  posterior  border.  The  parts,  including 
the  remaining  hair,  are  cleansed,  and  in  women  the  hair  is  braided  so 
as  to  draw  it  away  from  the  field  of  operation.  After  the  final  prepara- 
tion of  the  skin,  the  hair  in  the  neighborhood  is  plastered  down  with 
sterile  adhesive  plaster.  Before  applying  the  sterile  cloths,  the  incision 
is  outlined  with  the  point  of  a  knife.  This  incision  extends  from  in 
front  of  the  lobe,  upward  just  in  front  of  the  ear  to  a  point  1  centi- 
meter above  its  upper  free  border.  From  here  it  curves  forward  and 
then  downward  to  a  point  2^  centimeters  directly  in  front  of  the  upper 
end  of  the  attachment  of  the  ear  (Fig.  296).  After  this  incision  is 
outlined,  the  field  is  protected  above,  behind,  and  below  by  sterile 
cloths  that  are  pinned  in  place,  but  the  whole  of  the  facial  distribution 
of  the  seventh  nerve  should  be  left  entirely  within  the  operator's  un- 
obstructed view.  The  anesthetic  had  best  be  carried  on  by  a  spraying 
ether  vapor. 

The  incision  already  indicated  is  carried  through  the  skin  only,  and 
the  skin  flap  thus  outlined  is  dissected  downward,  retaining  with  it 
only  suflicient  tissue  to  insure  its  nourishment;  the  subjacent  superficial 
fascia  is  to  be  used  in  making  the  new  joint. 

The  second  step  consists  in  incising  the  superficial  fascia  down  to 
the  temporal  and  parotid  fasciae  and  the  zygoma  along  the  line  of  the 
skin-cut,  dissecting  it  up  from  the  subjacent  tissues  to  the  same  extent 
as  the  skin  flap.  In  doing  this,  only  the  posterior  three  fourths  of  the 
incision  in  the  superficial  fascia  should  be  made  at  first,  as  the  anterior 
end  of  the  incision  will  cross  the  branch  of  the  seventh  nerve  that  sup- 


DISEASES  OF  TEMPOROMANDIBULAR  JOINT. 


323 


plies  the  anterior  belly  of  the.  occipitofrontalis  muscle.  This  flap 
should  contain  the  temporal  artery  to  insure  its  vitality.  In  ex- 
tending the  incision  forward,  a  section  of  fascia  should  be  grasped 
sharply  in  a  pair  of  pointed  artery  forceps  before  being  cut.     If  a 


Fig.    296.      Showing    line    of    iiieioiou    for    exciiLion    of    the    temporomandibular    joint 
The  area  within  the  broad  pencil  marks  was  temporarily  anesthetic  afterward. 


Pig.   297.      X-ray 
moved  for  ankylosis. 


showing   condition  after   the   condyle   and   coronoid   process   are   re- 


motor  nerve  is  sharply  pinched,  there  will  be  a  contraction  of  the 
muscle  it  supplies.  If  necessary,  the  fibers  to  the  occipitofrontalis 
may  be  cut  or  stretched,  but  on  no  account  should  fibers  to  the 
orbicularis  palpebrarum  be  disturbed. 


324 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


The  posterior  part  of  the  masseter,  with  the  fascia  covering  it,  is 
to  be  freed  from  the  zygoma,  and  the  muscle  dragged  downward  and 
forward  with  a  small,  strong,  hooked  retractor.  This  will  expose  the 
site  of  the  joint,  which  may  be  found  surrounded  by  dense  adhesions  or 
an  overgrowth  of  bone,  or  there  may  be  a  true  ankylosis. 

If  by  cutting  the  periarticular  bands  the  mouth  can  be  opened  and 
the  interior  of  the  joint  appears  normal,  this  might  be  all  that  would  be 
needed,  but  we  have  never  encountered  such  a  case.  Usually  the 
condyle  will  have  to  be  resected,  or  the  bony  connection  dug  out  with 
grooved  chisels  and  a  small  rongeur  (Fig.  305).    To  one  accustomed  to 


Pig.    298. 


Pig.    299. 


Fig.    .300. 


Fig.    301. 


Fig.    302. 


Pig.  298.  Showing  opening  of  the  jaws  in  a  case  of  flbroosseous  ankylosis  in  a 
young  man  22  years  of  age,  in  whom  the  joint  on  one  side  had  been  injured  11  years 
previously  by  the  kick  of  a  mule.  The  movements  of  the  jaw  had  gradually  lessened 
until  the  opening  between  the  incisor  teeth  was  1  centimeter. 

Fig.  299.  Same  case  as  shown  in  Fig.  298,  after  excision  of  the  joint.  Opening 
between  the  incisor  teeth  24  millimeters. 

Fig.  300.  Case  shown  in  Fig.  298,  immediately  after  operation.  Mouth  held  open 
with   a  pine  block. 

Fig.  301.  Case  shown  in  Pigs.  298  to  300,  one  year  and  nine  months  after  operation. 
Opening  between  incisor  teeth  35  millimeters. 

Fig.  302.  Showing  opening  that  was  obtained  in  a  case  of  single  complete  anky- 
losis, after  cutting  the  rami  and  drawing  forward  the  body.  Later  this  opening  de- 
creased, and  the  ankylosed  joint  was  reconstructed  with  a  permanent  good  result. 


DISEASES  OF  TEMPOROMANDIBULAR  JOINT. 


325 


work  with  them,  burs  driven  by  an  engine  would  do  effective  work, 
but  it  is  to  be  Temembered  that  the  internal  maxillary  artery  and  part 
of  the  third  division  of  the  fifth  nerve  lie  immediately  subjacent  to 
the  bone. 

The  serious  question  has  occurred  to  us,  in  removing  both  condyles 
simultaneously, of  the  possibility  of  the  masseter  and  internal  pterygoids 
drawing  the  mouth  permanently  open.  In  one  case  of  a  five-year-old 
child  we  removed  both  condyles  at  the  same  time,  and  the  child  closes 
its  mouth  perfectly.  Simple  excision  of  one  or  both  condyles  for  anky- 
losis is  an  old  operation  and,  as  far  as  we  know,  has  not  been  followed 
by  inability  to  close  the  mouth. 


Pig.  303.  Shows  girl  of  16  years,  in  whom,  as  a  result  of  an  infectious  arthritis, 
there  was  an  almost  complete  fibroosseous  ankylosis  of  the  right  side — ^first  noticed  at 
3  years.  At  16  years  she  had  an  opening  of  3  millimeters  on  the  right  and  of  4  milli- 
meters on  the  left  in  the  canine  region.  The  right  condyle  was  excised,  and  a  new 
joint  made.  The  left  ramus  was  sawed  in  two,  and  the  body  dragged  forward  and 
wired  In  Its  position.  Later  a  piece  of  her  seventh  costal  cartilage  was  Implanted  in 
front  of  the  mental  part  of  the  body  of  the  jaw.  Shortly  after  unwiring  the  jaw,  she 
had  an  opening  of  18  millimeters. 


A  true  ankylosis  will  usually  obliterate  the  sigmoid  fossa  and  in- 
volve the  coronoid  process.  If  possible,  a  part  of  the  insertion  of  the 
temporal  muscle  should  be  preserved,  but  this  is  rarely  the  case.  The 
ankylosis  having  been  freed,  the  mouth  is  opened.  Even  where  there 
has  been  no  injury  or  disease  of  the  joint  of  the  opposite  side,  this 


326 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


may  not  be  easy  and  may  require  a  strong  dilator.  Judgment  must 
be  used;  for  it  is  in  just  such  a  case  that  the  jaw  may  be  fractured  or 
several  teeth  pushed  out.  If  the  mouth  cannot  be  opened,  the  oper- 
ation must  be  repeated  on  the  other  side.  A  2-centimeter  space  between 
the  cuspids  is  a  practical  amount.  If  the  jaws  are  forced  too  wide 
apart,  the  muscles  of  mastication  might  be  injured  beyond  recovery. 
If  the  bony  and  ligamentous  resistance  has  been  overcome,  the  amount 
of  the  opening  will  subsequently  increase  with  use  (Figs.  298  to  302). 
The  joint  is  made  permanent  by  suturing  the  flap  of  superficial  fascia 
to  some  soft  tissue  at  the  bottom  of  the  defect,   left  after  removing 


Fig.  304.  Case  shown  in  Pig.  303,  eight  luonths  after  first  operation.  She  has 
an  opening  of  22  millimeters,  has  gained  considerably  in  weight,  and  her  general  ap- 
pearance and  mode  of  dress  show  her  improved  disposition. 

the  condyle.  Before  doing  this,  hemorrhage  must  be  controlled  so  as 
to  obtain  a  clear  view.  The  artery,  vein,  or  nerve  might  be  injured 
in  passing  this  suture.  If  the  original  incision  has  not  been  carried 
sufficiently  high  on  the  temple,  the  facial  flap  may  be  too  short ;  it  could 
be  lengthened  by  cutting  downward  in  front,  but  injury  to  the  palpebral 
fibers  of  the  motor  nerve  must  be  avoided.  If  the  flap  is  absolutely 
too  short,  the  zygoma  may  be  cut,  and  a  section  of  the  temporal  muscle 
substituted  for  it.  The  flap  having  been  sutured  into  the  new  joint, 
the  skin  wound  is  closed  with  a  rubber  dam  drain  extending  to  the 


DISEASES  OF  TEMPOROMANDIBULAR  JOINT. 


327 


depth  of  the  new  joint  and  let  out  in  front  of  the  tragus.  This  drain 
should  be  sutured  to  the  skin.  Usually  our  next  step  is  to  fix  the 
mouth  open  by  wiring  a  smooth  block  of  pine  wood  between  the  molars 
on  one  side,  that  will  separate  the  jaws  about  2  centimeters.  This 
will  cause  some  discomfort,  but  will  insure  a  free  opening.  The  pa- 
tient will  be  able  to  close  the  jaws  within  twenty- four  or  forty-eight 
hours  after  removal  of  the  block.  A  free  motion  will  develop  and  will 
increase  with  time.  If  there  is  the  retraction  of  the  chin  that  always 
accompanies  a  very  early  ankylosis,  the  ramus  is  sectioned  on  the  sound 
side,  and  the  body  is  drawn  forward  and  held  in  place  by  wiring  the 
upper  to  the  lower  teeth  (Fig.  36).  At  the  end  of  ten  or  twelve  weeks 
the  wires  are  removed,  and  the  opening  gradually  restored  with  rubber 
wedges. 


Fig.   305.      Showing  cavity  remaining  after   removing   ankylosed   condyle.      Also    flap 
of  fascial  tissue  that  is  to  be  sutured  to  the  bottom  of  the  cavity. 


As  with  any  operation  around  the  parotid  gland,  a  temporary  paral- 
ysis of  the  muscles  supplied  by  the  seventh  nerve  may  follow,  becoming- 
evident  within  the  first  two  days.  This  is  chiefly  evidenced  by  the 
eye  remaining  open  while  asleep.  It  should  not  cause  worry,  for,  ac- 
cording to  our  observation,  it  always  disappears  in  three  to  five  weeks. 
Paralysis  due  to  direct  injury  of  the  nerve  comes  on  immediately.  If 
one  were  unfortunate  enough  to  cut  the  whole  supply  of  the  orbicularis 
palpebrarum,  the  nerve  should  be  sought  and  sutured  immediately.  In 
one  case  we  had  a  partial  injury  to  the  nerve  supply  of  the  muscle,  but 
ability  to  completely  close  the  palpebral  fissure  was  restored  within  six 
months. 


CHAPTER  XXIII. 

FRACTURES   AND  DEFORMITIES   OF  THE   EXTERNAL 

NOSE. 

Simple  fracture  of  the  nose  is  a  common  occurrence.  The  ex- 
ternal nose  may  be  completely  or  partially  destroyed  by  ulceration, 
most  commonly  syphilis,  or  from  trauma.  Traumatic  destruction  may 
be  a  part  of  a  more  extensive  injury. 

Simple  fractures  may  be  grouped  chiefly  into  two  classes :  Cir- 
cumferential fractures  in  which  both  nasal  bones  are  loosened  from 
their  maxillary  and  frontal  attachments  with  or  without  deformity, 
due  to  a  lateral  blow ;  and  crushing  fractures  due  to  violence  applied 
in  a  frontal  direction.  In  the  latter  case  there  is  usually  a  partial 
circumferential  fracture  with  a  separation  of  the  bones,  or  a  crushing 
in,  in  the  midline.  Deformity  may  vary  from  a  slight  flattening  and 
broadening  of  the  bridge  to  a  complete  flattening  of  the  nose  with 
shortening  and  an  upward  tilt  of  the  tip.  If  these  injuries  occur 
early  in  childhood,  the  deformity  may  lessen  or  very  much  increase 
with   growth. 

TREATMENT  OF  FRACTURES  OF  THE  NOSE. 

In  considering  treatment,  the  cases  must  be  divided  into  two 
more  classes :  early  cases  in  which  bony  union  is  not  complete ;  and 
late   cases   with   deformity. 

Early  Cases. — If  there  is  no  deformity,  then  no  special  surgical 
treatment   is   indicated. 

In  circumferential  fractures  with  lateral  displacement,  the  nose 
is  to  be  pushed  to  the  midline,  this  being  determined,  even  in  the 
presence  of  considerable  swelling,  by  making  an  ink  spot  of  the 
dorsum  of  the  nose,  near  the  tip,  at  the  lower  end  of  the  bony  bridge, 
and  midway  between  the  brows.  When,  if  viewed  from  above,  these 
three  dots  are  in  a  line  and  are  on  a  line  with  the  middle  of  the  chin, 
the  nose  has  been  restored  to  the  proper  position.  In  most  cases 
when  this  is  done  early,  the  fragments  will  stay  unaided  in  their 
proper  position.  If  the  deformity  tends  to  recur,  it  is  best  overcome 
by  the  method  shown  in  Fig.  205. 

If  the  nose  is  crushed  in,  then  the  bridge  is  to  be  pried  out  by 
some  smooth  instrument  passed  into  the  nostril,  such  as  a  small  steel 

328 


FRACTURES,  DEFORMITIES  OF  EXTERNAL  NOSE.  329 

urethral  sound.  If  deformity  recurs,  it  may  be  helped  by  intranasal 
hollow  splints,  but  is  best  supported  by  one  or  two  No.  16  German 
silver  or  gold-plated  hard  drawn  brass  pillars  anchored  to  a  jacket 
splint  on  the  upper  teeth,  passing  through  the  soft  tissues  at  the  upper 
fornix  of  the  lip  into  the  nasal  cavities  and  supporting  the  nasal 
bridge  from  the  inside  (Fig.  306).  Little  help  or  comfort  has  been 
derived  from  external  splints  and  contrivances. 

Old  Fractures  with  Deformity. — The  deformity  may  be  due 
entirely  to  the  original  violence  or  it  may  have  appeared  and  increased 
with  body  growth.  This  brings  us  to  the  treatment  of  deformities 
of  the  nose  which  may  be  divided  into  two  classes :  those  without 
loss  of  substance,  and  those  with  loss  of  substance.  In  the  former 
will  be  included  not  only  those  that  have  resulted  from  fracture,  but 
also  under  this  heading  will  come  certain  congenital  deformities  and 


Fig.   306.      Nasal   bridge   supported   from    the   teeth. 

saddle  nose  due  to  injury  or  to  syphilitic  destruction  of  the  bones. 

As  in  fractures,  the  deformities  fall  into  two  main  groups,  lateral 
displacement  and  flattening  of  the  bridge,  with  the  addition  of  a  class 
distinguished  by  too  prominent  a  bridge. 

Lateral  displacement  is  corrected  by  the  method  shown  in  Chap. 
XVII,  Fig.  205. 

If  the  displacement  occurs  in  early  grozvth,  then  the  cartilage  grows 
in  a  deformed  manner  so  that  the  tip  is  drawn  over  to  the  same  side 
with  a  bulge  of  the  cartilage  externally  on  that  side,  and  the  carti- 
laginous dorsal  ridge  runs  from  the  suture  of  junction  of  the  two 
nasal  bones  to  this  cartilaginous  bulge  (Fig.  307).  Drawing  the 
bony  ridge  to  the  midline  will  not  entirely  correct  the  deformity. 
This  is  best  done  by  making  a  transverse  cut  across  the  bridge  above 


330 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  cartilaginous  bony  junction  and  freeing  the  soft  tissues  from  the 
cartilaginous  prominence  by  undermining.  A  section  of  cartilage  is 
taken  from  the  ridge  and  bump  and  transplanted  to  the  midline  and 
held  by  one  or  two  fine  silk  sutures.  All  bleeding  is  stopped  by 
pressure  or  ties,  and  the  transverse  cut  closed  by  fine  sutures  to  be 
removed  the  next  day  and  a  collodion  dressing  substituted. 

Depressed  Bridge   is   best  treated  by   cartilage  transplantation 
made  external  to  the  bridge.     The  deformitv  in  these  cases  consists 


/; 

u ianif 

1 

B 


C 


Fig.  307.  Girl  sixteen  years  of  age  who  at  about  three  years  received  a  blow  on 
the  nose  with  little  apparent  deformity.  Later,  with  growth,  the  deformity  shown  in  A 
appeared.  Replacing  the  bridge  gave  the  condition  shown  in  B.  A  plastic  operation 
on  the   cartilage   gave   the   condition   showin    in   C. 


primarily  in  the  flat  bridge,  but  secondarily,  the  nose  is  shortened, 
the  tip  upturned,  and  the  distance  between  the  inner  canthi  increased. 
These  can  all  be  partially  or  completely  remedied  by  insertion  of  a 
properly  shaped  piece  of  cartilage.  The  cartilage  is  to  be  cut  triangular 
in  shape  with  some  slight  bowing  of  the  long  border  which  is  the 
natural  border  of  the  cartilage  (Fig.  308/i).  Out  of  a  piece  of  tin  a 
pattern  is  cut  and  trimmed  so  that  with  the  border  d-e  resting  upon  the 
flattened  bridge,  the  border  c-c  will  form  the  new  nasal  ridge,  while 


FRACTURES,  DEFORMITIES  OF  EXTERNAL  NOSE. 


331 


the  pyramidal  piece,  of  which  c-d  forms  one  side,  will  project  down- 
ward and  forward  sufficiently  far  to  give  the  nose  the  proper  length 
and  the  tip  the  proper  prominence.  This  portion  of  the  cartilage  is 
held  forward  by  the  anchorage  of  the  side  d-e  to  the  bony  bridge  and 
the  pressure  of  soft  tissues  across  the  upper  part  of  the  nose  (Fig. 
3085). 

The  new  bridge  in  its  upper  part  must  be  sufficiently  prominent  to 
draw  the  inner  canthi  to  their  proper  positions  and  to  accomplish 
this  it  may  be  necessary  to  round  the  border  d-e  (Fig.  308.4)  to  con- 


Fig.  308A.  Diagrammatic  repre- 
sentation of  the  right  costal  cartilages 
from  which  cartilaginous  grafts  are  ob- 
tained. 


Fig.    '308B.      Depressed    bridge     ele- 
vated   by   cartilage   transplant. 


form  to  the  junction  of  the  nasal  and  frontal  bones.  The  piece  of 
cartilage  is  obtained  with  as  much  periosteum  as  possible  under  local 
anesthetic  from  the  7th,  8th,  9th,  or  10th  cartilage.  A  sufficiently 
large  piece  is  obtained,  laid  on  a  freshly  opened  sterile  towel,  and, 
while  held  with  toothed  forceps,  is  trimmed  according  to  the  pattern, 
and  then  dropped  back  into  the  original  wound  for  safe  keeping.  A 
transverse  incision  is  made  to  the  bone  across  the  bridge  correspond- 
ing to  the  site  of  a  spectacle  bow,  and  the  tissues  tunneled  upward 


332 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


to  the  prominence  of  the  brow  above,  and  down  nearly  to  the  tip. 
Laterally  the  tunneling  is  made  no  wider  than  necessary  to  receive 
the  graft.  Without  it  ever  having  been  touched  with  the  fingers, 
the  graft  is  slipped  into  place,  the  borders  of  the  wound  being  re- 
tracted so  as  not  to  touch  the  graft  as  it  is  slipped  in.  The  end  e 
is  in  the  frontal  prominence,  c  is  the  tip  and  c-e  the  new  ridge.  If 
needed  the  e  end  may  be  anchored  by  a  suture  or  a  fine  brad  nail, 
hemorrhage  controlled,  and  the  skin  closed  with  fine  suture  which 
are  removed  next  day  and   a  collodion   dressing  applied.     On  both 


A  B 

Fig.  309.  A  shows  the  deformity  which  resulted  from  an  injury  that  tore  the 
cartilages  from  the  lower  border  of  the  bony  bridge  without  tearing  the  skin.  B  shows 
the  result  after  cutting  the  cartilages  from  their  false  attachment  and  suturing  them  in 
proper  position.     Operation  was  done  through  a  transverse  skin  incision. 


sides  of  the  new  bridge  flufl^ed  gauze  is  piled  high  and  a  starch  band- 
age applied  that  does  not  press  on  the  tip  of  the  nose.  In  many 
of  these  cases  subsequent  or  previous  intranasal  operations  will  be 
required   to    restore   the   breathing   space. 

The  whole  cartilaginous  part  may  be  torn  loose  from  the  lower 
border  of  the  bony  bridge  by  an  open  or  a  subcutaneous  separation 
(Fig.  309). 

In  this  case  a  transverse  incision  is  made  across  the  bridge,  the 
cartilage  restored  to  its  normal  position  and  sutured  there.  If  an 
old  injury  is  being  treated  it  is  necessary,  before  attempting  to  replace 
the  cartilage  to  surround  the  lower  end  of  the  bridge  by  a  bevel  cut 
which  frees  the  cartilage  from  the  bones. 


FRACTURES,  DEFORMITIES  OF  EXTERNAL  NOSE. 


333 


Prominence  of  the  Bridge,  when  too  great,  may  be  treated 
by  raising  a  trapdoor  flap  over  the  prominence  and  shaving  it  ofif 
(Fig.  310).  If  the  nasal  fossae  rise  up  into  the  prominence,  as  may 
be  determined  by  previous  x-ray  or  transillumination,  then  if  the 
prominence  were  simply  shaved  off,  there  would  result  two  longi- 
tudinal depressions  corresponding  to  the  fossae.  In  such  a  case,  after 
turning  the  trapdoor,  a  thin  shaving  of  bone  and  cartilage  is  removed 


Fig.  310.  A  shows  a  too  prominent  bridge,  the  nasal  fossa  extending  well  into  the 
hump.  B  shows  result  after  baring  the  bone  and  cartilage  through  a  trapdoor  incision, 
shaving  off  a  graft  of  bone  and  cartilage  from  the  hump,  cuttting  out  sufficient  bone  and 
cartilage  to  obliterate  the  hump,  and  then  replacing  the  graft  as  a  roof  to  the  exposed 
nasal   fossae. 

in  one  piece,  to  be  later  returned.  Then  sufficient  bone  and  cartilage 
is  bitten  away,  without  opening  the  lining  mucosa,  to  remove  the 
objectionable  bump,  allowing  for  the  graft  that  is  to  be  returned.  The 
graft  shaved  off  originally  is  sutured  into  place  as  a  roof  to  the  nasal 
fossae,  the  trapdoor  flap  sutured  into  place,  and  a  mild  pressure  band- 
age applied.     In  doing  such  work  one  must  use  his  artistic  eye. 

In  the  enlargement  of  the  nose  that  may  follow  seborrhea,  pieces 
of  the  nostrils  and  of  the  bulbous  end  may  be  removed  and  the  defects 
closed  by  suture. 


334  SURGERY  OF  THE  MOUTH  AND  JAWS. 

In  rhynophyma,  after  controlling  the  inflammation,  the  promi- 
nences are  shaved  off  and  whole  areas  of  thickened  skin  may  be  remov- 
ed, and  the  raw  surfaces  grafted. 

Deformities  Due  to  Loss  of  Soft  Tissues. — In  the  past,  as  a 
rule,  operations  for  the  restoration  of  the  whole  or  most  of  the 
external  nose,  have  not  been  satisfactory  due  chiefly  to  lack  of  regard 
for  what  is  demanded  to  make  a  cosmetic,  functional  organ\ 

Eloesser-  sums  up  part  of  the  past  history  of  this  as  follows : 

"Men  are  again  beginning  to  push  forward  along  the  paths  first  opened 
by  Dieffenbach,  Nelaton,  Langenbeck  and  their  compeers — paths  where 
work  had  almost  ceased  these  fifty  years.  Plastic  surgery  of  the  face  is 
ancient;  one  can  read  of  plastics  of  the  nose  in  Sanscrit  writings.  The 
Hindu  surgeons  had  abundant  opportunity  of  treating  patients  whose  noses 
had  been  cut  off  in  war  or  in  captivity.  They  are  said  to  have  used  a  free 
transplantation  from  the  buttocks,  which  were  made  hyperemic  before 
operation  by  flagellation.  Attempts  by  French  surgeons  in  the  beginning 
of  the  last  century  to  reproduce  these  operations  failed.  Dieffenbach  in 
the  middle  of  the  last  century  devised  many  plastic  operations  on  the 
face  and  the  nose  and  carried  them  out  with  success.  It  was  Schimmel- 
busch,  however,  who  first  enunciated  the  principles  underlying  every  suc- 
cessful nasal  reconstruction,  viz.:  that  the  new  nose,  if  it  is  not  to  shrink 
and  to  sink  to  a  shapeless  mass,  must  have  a  lining  of  epithelium  and  a 
support  of  bone.  He  took  his  material  from  the  forehead,  making  a  flap 
of  skin,  subcutis,  periosteum  and  outer  layer  of  the  frontal  bone.  Lexer 
has  recently  elaborated  Schimmelbusch's  ideas  to  a  high  degree,  and 
shows  some  most  notable  drawings  and  photographs  in  his  article  (Archiv. 
f.  Klin.  Chir.,  xcii,  749).  He  insists  upon  the  necessity  of  covering  both 
the  cavities  of  the  nose  and  the  bony  flaps  with  sound  epithelium,  and  of 
working  in  healthy  tissues;  he  uses  all  remnants  and  tabs  of  the  old  nose 
to  this  end,  instead  of  utilizing  them  to  patch  into  the  new  one.  Lexer's 
work  signalizes  the  highest  development  of  the  modern  plastic." 

Flaps  may  be  obtained  from  forehead,  cheek,  neck  or  arm,  and 
the  bone  may  be  taken  up  originally  as  osteoplastic  grafts  from  the 
forehead  or  maxillary  bones.  Bone  or  cartilage  grafts  may  be  im- 
planted into  the  flaps  before  or  after  they  are  applied  to  the  nasal 
defect  (see  Chap.  XIX),  but  to  obtain  desirable  results  the  rules  laid 
down  by  Eloesser  must  be  complied  with.  Wolkowitsch  was  the  origi- 
nator of  the  use  of  the  finger  to  furnish  bone  and  soft  tissue,  but  this 
last  plan  has  been  worked  out  on  more  scientific  lines  by  E.  G.  Blair^, 
of  Kansas  City,  whose  presentation  of  the  subject  follows : 

"Dactylocostal  (Osseous  and  Cartilaginous)  Rhinoplasty. — The  method 
here    presented    for    the    total    absence    of   a   nose    embraces    the    use    of   a 


iFor  a  more  detailed  description  of  the  treatment  of  nasal  deformities,  see  chapter 
on  "Plastic  Surgery  of  the  Nose  and  Ear"  by  Dr.  Joseph  C.  Beck,  in  Vol.  I  of  Loeb's 
"Operative  Surgery  of  the  Nose,  Throat,  and  Bar,"  C.  V.  Mosby  Company,  St.  Louis,  1917. 

2Eloesser,   L.  :      California   State   Medical   Journal,   August,    1911. 

SBlalr,  B.  G. :     Surgery,  Gynecology,  and  Obstetrics,  December,  1914,  XIX,  718-24. 


FRACTURES,  DEFORMITIES  OF  EXTERNAL  NOSE.         335 

finger,  out  of  which  the  essentials  are  first  constructed  before  attachment 
to  the  face.  The  ring  finger  of  the  left  hand  is  selected,  split  throughout 
its  entire  length  on  the  anterior  surface,  and  cross-sectioned  at  the 
proximal  flexion  through  the  tendons  down  to  the  bone.  The  skin  and 
subcutaneous  tissue  of  one  side  is  laterally  dissected  well  around  to  the 
dorsum;  a  similar  dissection  of  the  other  side  carries  with  it  all  the 
tendinous  tissue,  leaving  the  front  of  the  phalanges  bare  of  soft  tissue  and 
the  finger  trebled  in  dorsal  width,  to  maintain  which  the  margins  are 
sutured  to  a  plate  of  celluloid  applied  on  the  back.  The  distal  joint  is 
excised  for  ankylosis.  To  further  maintain  this  width  and  furnish  the 
foundation  of  the  septum,  a  flap  of  skin  and  subcutaneous  tissue  is  turned 
back  from  the  chest  wall,  as  was  done  by  Baldwin^,  larger  in  dimensions 
than  the  split  surface  of  the  finger,  and  left  attached;  up  to  this  attachment 
the  opening  is  immediately  sutured.  The  finger  is  now  brought  into  con- 
tact with  the  chest  flap,  raw  surfaces  together,  and  sutured  at  the  margins. 
This  position  is  kept  for  one  week  by  adhesive  slings  at  the  end  of  which 
time  section  of  the  flap  from  the  chest  is  made  under  local  anesthesia,  and 
its  amalgamation  with  the  widened  finger  is  allowed  to  grow  to  the  state 
of  perfection.  When  this  is  reached,  the  half  of  the  finger  carrying  the 
tendons  is  again  split  from  the  margin  to  and  beyond  the  median  line 
throughout  its  length  in  a  flat  plane  and  beneath  the  tendons.  This  flap 
then  is  flatly  turned  over  on  its  other  half  as  the  leaf  of  a  book,  exposing 
the  double  raw  surface,  over  which  one  Thiersch  skin  graft  is  immediately 
applied.  When  this  has  healed,  a  free  comb  of  tissue  projects  from  the 
middle  of  the  finger — made  up  on  one  side  of  chest-wall  flap,  on  the  other 
of  Thiersch  graft  with  tendinous  and   subcutaneous  tissue  in  between. 

"As  soon  as  these  newly  fashioned  tissues  become  pliable,  and  before 
too  much  shrinkage  occurs,  the  finger  is  applied  to  the  face  in  the  following 
manner:  The  margin  of  the  facial  opening  is  incised  throughout  its  entire 
circumference  well  inside  the  nasal  cavity.  The  contiguous  soft  tissue  on 
the  cheeks  is  freely  lifted  with  a  periosteal  elevator. and  is  carried  well  up 
to  the  frontal  bone  above.  A  small  flap  is  now  turned  up  from  the  floor 
of  the  nasal  cavity  and  left  attached  at  the  median  line;  a  similar  flap  is 
sought  in  any  available  tissue  inside  the  cavity  above.  In  the  finger,  the 
nail  and  dorsal  tissues  are  removed  back  to  the  distal  knuckle  and  the 
bone  made  bare;  the  margins  are  freshened  by  turning  a  small  Lane  flap 
from  above  downwards  as  far  in  length  as  the  middle  knuckle,  the  flaps 
slipped  under  raw  edges  of  the  facial  tissue  with  the  integumental  surface 
toward  the  nostril.  Similarly  freshened-  margins  are  made  on  the  finger 
comb  to  be  attached  to  the  nasal  flaps  above  and  below.  The  bare  unguinal 
phalanx  is  now  passed  under  the  edges  of  the  soft  tissues  above  and 
anchored  by  a  suture  passed  through  them  and  the  phalanx  and  tied  over 
a  piece  of  gum  tubing.  The  marginal  face  and  finger  tissues  are  sutured 
with  simple  interrupted  sutures  of  silk.  A  cross-section  of  these  assembled 
tissues  is  seen  in  Fig.  311. 

"The  finger  is  held  in  contact  with  the  face  as  illustrated  in  a  plaster 
cast.  The  length  Of  time  it  should  be  kept  so  is  not  determined  by  days, 
but,  after  five  days,  by  tourniqueting  the  finger  with  a  small  rubber  band, 
shutting  the  blood  supply  from  the  hand,  and  observing  the  circulation 
from  the  face.    The  opinion  is  now  well  established  that  this  procedure  done 


^Baldwin :     Surgery,  Gynecology,  and  Obstetrics,  1912,  xv,  720. 


336 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


5UP.  MAX 


Pig.  311.  A-A,  widened  dorsum  of  finger ;  B-B,  skin  of  chest-wall  lining ;  C-C, 
Thiersch  gi-aft  lining;  D-D,  lifted  facial  tissues;  E,  bone  of  finger;  F-F,  tissue  covering 
nasal  floor. 


Fig.  312.      A,  rib-cartilage  ;  B,  rib  ;  C,  silver  wire  anchorage  into  jaws  of  split  finger  ; 
D,  chest-wall  integument. 


Pig.  313.  A,  complete  nasal  integument ;  B,  flap  turned  from  inside  nose  ;  C,  flap 
turned  up  from  floor  of  nasal  cavity ;  D,  dorsal  flap  of  skin  turned  down  from  finger ;  E, 
bone  of  finger;  F.  granulating  surfaces  unexposed. 


FRACTURES,  DEFORMITIES  OF  EXTERNAL  NOSE.  337 

each  day  for  from  fifteen  to  thirty  minutes  under  inspection  stimulates  the 
establishment  of  the  fac'io-finger  circulation  and  reduces  the  length  of  time  in 
the  cast.  In  the  original  case  amputation  was  made  in  nineteen  days;  but  it 
was  recognized  that  it  could  have  been  separated  in  fourteen.  Another 
physiological  observation  worthy  of  note  is  that  at  the  end  of  ten  days  the 
knuckle)  feels  like  my  nose,  the  rest  of  it  is  like  my  finger.'  When  the  cir- 
culation is  thoroughly  established  from  the  face,  amputation  'is  done  at  the 
meto-carpophalangeal  articulation,  and  the  projecting  phalanx  is  reflected 
backward  so  that  the  middle  articulation  can  be  removed  with  a  rongeur  to 
patient  voluntarily  said,  'My  finger  down  to  there  (meaning  the  middle 
ease  the  tension  in  the  dorsal  tissues  and  prevent  the  ischemia  resulting 
from  extreme  flexion  of  this  phalanx  when  it  is  set  into  the  tissues  covering 
the  superior  maxilla  to  secure  projection.  Before  this  is  done  the  soft 
tissues  of  the  phalanx  are  slit  on  each  side  close  to  the  bone  and  carried 
to  the  face  for  suturing.  The  middle  portion  is  set  into  a  transverse 
incision  made  into  the  maxillary  tissues  down  to  the  bone  and  sutured  in 
place.  Freshened  edges  of  the  septal  tissue  are  made  and  brought  into  con- 
tact as  the  flexion  is  made,.  There  are  now  no  raw  surfaces  exposed  except 
the  margins  of  the  slits,  and  into  these  gum  tubes  are  placed,  to  allow  for 
healing  and   formation   of   the   nostrils. 

"If  for  any  reason  there  is  insufficient  projection,  or  if  from  contraction 
more  tissue  is  desired,  the  following  plan  may  be  utilized  successfully: 
A  flap  of  chest  wall  is  again  used  similar  in  shape  to  that  used  before,  l)Ut 
made  over  a  rib  including  its  cartilage  and  all  the  tissues  down  to  the 
pleura;  the  cartilage  of  the  rib  is  sectioned  and  the  free  end  in  the  llap 
turned  up.  The  soft  tissues  of  the  middle  finger  of  the  left  hand  are  now 
split  in  a  flat  plane  anterior  to  the  bony  phalanx  back  to  the  distal  (lexion. 
Into  the  jaws  of  this  incision  the  projecting  rib  cartilage  is  set  and 
anchored  by  a  silver  wire  inserted  along  one  side  of  the  nail  inward  and 
through  the  cartilage  and  out  again  on  the  other  side,  the  ends  being 
twisted  ovei:  a  piece  of  tubing  placed  over  the  nail.  The  skin  of  the  upi)er 
jaw  of  the  finger  is  sutured  to  the  free  end  of  the  skin  of  the  chest  wall, 
and  contact  of  the  lower  finger  flap  is  made  by  the  introduction  of  packing 
introduced  to  elevate  the  rib  and  prevent  its  reunion.  Aften  ten  days, 
section  of  the  rib-flap  was  completed  one  and  one-half  inches  away  from 
the  point  of  finger  contact.  In  this  way  the  finger  was  made  the  carrier 
of  chest  wall,  including  skin,  rib  and  cartilage  (Fig.  312),  one  and  one-half 
inches  in  length  by  one  inch  in  width.  This  union  was  continued  with  the 
hand  free  on  a  simple  splint  until  the  vitalization  and  formation  of  the 
graft  was  what  was  desired.  Three  weeks'  time  was  given  to  this,  with 
only  slight  shrinkage.  The  former  finger  nose  was  then  split  in  the 
median  line  from  a  point  above  desired  to  the  tip,  down  to  the  bone,  and 
the  nasal  covering  dissected  off  laterally,  making  two  wings  of  soft  tissue — 
former  dorsum  of  the  finger.  Perfectly  healthy  bone  and  septum  were 
revealed,  but  were  somewhat  retracted.  The  margins  of  the  chest-wall 
graft  were  freshened,  as  were  those  of  the  widened  finger,  and  this  tissue 
was  superimposed  on  the  exposed  bone,  with  which  its  freshened,  granulat- 
ing under  surface  was  brought  into  contact.  Anchoring  facial  suturing  and 
maintenance  was  the  same  as  before.  On  the  tenth  day  the  finger  tourni- 
quet indicated  the  feasibility  of  sectioning  the  finger  from  the  graft,  which 
was   done,  leaving  a  vital   rib   implanted  with   chest-wall   skin,   growing,   a 


338  SURGERY  OF  THE  MOUTH  AND  JAWS. 

fixed  part  of  the  nose.  The  small  fragment  of  cartilage  left  in  the  finger 
was  removed  and  the  finger  restored. 

"When,  in  the  case  of  a  collapsed  nose,  a  finger  is  used,  as  was  done 
by  Finney^,  a  primary  plastic  sectioning  is  done  for  the  construction  of 
the  septum.  Starting  well  over  to  the  left  side  of  the  nasal  covering  a  flap 
is  dissected  off  on  the  inside  of  mucous  membrane,  with  some  effort  to 
include  portions  of  cartilage,  and  the  dissection  is  carried  well  over  to 
a  point  opposite  and  left  attached  to  hang  down.  A  similar  flap  is  turned 
up  from  the  nasal  floor  to  join  this.  When  the  dorsum  of  the  finger  is 
denuded,  it  is  done  by  making  a  flap  of  those  tissues,  starting  well  over  on 
the  left  margin  of  the  dorsum  and  carrying  the  dissection  to  the  middle 
of  the  anterior  surface  of  the  finger,  where  it  is  left  to  hang  with  its  raw 
surface  to  be  apposed  to  the  raw  surfaces  of  the  two  nasal  flaps  already 
made;  making  a  completely  lined  septum,  and  with  the  surface  created 
above  by  the  dissection  from  the  nasal  integument  coming  into  contact 
with  the  denuded  finger,  no  raw  surface  whatever  'is  left.  The  assemblage 
of  these  tissues  in  section  is  illustrated  in  Fig.  313.  The  phalanx  remaining 
for  projection  is  freshened  only  at  the  point  where  it  joins  the  septum, 
and  its  shrinkage  is  left  to  tube  pressure  in  the  nostrils,  which  is  kept 
up  until  it  is  accomplished,  most  of  the  time  being  inserted  only  at  night. 
By  the  sacrifice  of  a  finger  in  this  way  a  perfect  result  can  be  obtained; 
but  with  the  success  of  a  chest-wall  transplantation,  it  is  obvious  that 
with  the  application  of  a  Thiersch  graft  to  its  under  raw  surface  it  could 
as  well  be  used  in  much  the  same  manner   and  the  finger   saved. 

"In  the  correction  of  the  'saddle  nose,'  the  method  of  transplantation 
of  a  chest-wall  flap  was  put  to  a  second  test.  In  a  moderately  depressed 
nose  the  rib  was  attached  to  the  finger  as  before,  but  after  sectioning  from 
the  chest  wall  its  dorsal  skin  was  lost  by  sloughing,  probably  from  insecure 
suturing  to  the  finger  or  undue  mobility  subsequently.  The  integrity  of 
the  other  tissues,  however,  was  preserved,  and  in  two  weeks,  the  rib- 
cartilage  was  completely  enveloped  in  a  most  prolific  covering  of  healthy 
granulations.  To  apply  this  to  the  nose  the  columna  was  divided  at  its 
junction  with  its  dorsal  cartilages  and  the  section  carried  through  the 
septum  to  the  margins  of  the  nasal  bones;  the  depressed  soft  tissues  were 
then  freely  elevated  on  both  sides  and  above.  The  granulations  on  the 
graft  were  shaved  well  down  to  the  cartilage  until  it  was  fashioned  exactly 
to  correct  the  deformity;  then  it  was  passed  into  the  nasal  pocket  created 
for  it,  anchored,  sutured,  and  kept  in  a  cast  much  as  before.  This  was 
maintained  for  only  one  week,  when  it  was  separated  from  the  finger  and 
has  remained  perfect  without  shrinkage.     The  columna  later  was  restored." 

In  our  own  work  on  the  subject  we  have  preferred  to  make  the 
bridge  of  cartilage  anchored  above  so  as  to  project  sufficiently  to 
maintain  the  prominence.  On  the  cadaver  we  have  worked  out  a 
plan  of  using  the  edge  of  the  scapula,  transplanted  first  with  the  fore- 
arm and  then  to  be  placed  in  the  defect,  the  general  technique  being 
somewhat  after  the  plan  described  by  E.  G.  Blair,  except  that  the 
septum  would  be  bony,  formed  from  the  thin  part  of  the  scapula 
blade.     We  have  been  deterred  from  applying  this  to  the  living  patient 


spinney  :      Surgery,  Gynecology,  and  Obstetrics,  1907,  v,  23. 


FRACTURES,  DEFORMITIES  OF  EXTERNAL  NOSE.  339 

because  we  are  not  convinced  that  the  septum  is  a  necessity,  and  if 
the  nose  can  be  supported  from  the  forehead  any  thin  strip  of  tissue 
will  serve  as  a  columella.  Bony  or  cartilaginous  union  can  be  ob- 
tained by  supporting  the  lower  end  of  the  new  bridge  by  the  brace 
attached  to  the  teeth  (Fig.  306)  and  the  fear  that  if  the  patient 
subsequently  becomes  obese  that  fat  deposit  in  the  subcutaneous  tis- 
sues of  the  intranasal  grafts  might  obstruct  the  respiratory  passages. 

This  is  complicated  surgery,  and  should  not  be  undertaken  without 
first  having  all  details  of  each  step  perfectly  projected  in  the  operator's 
mind,  and  it  is  well  to  try  the  various  steps  on  the  cadaver. 

In  the  preceding  description  little  more  than  principles  have  been 
given,  but  these  are  sufficient  to  one  with  a  special  training  in  plastic 
work.     Space  does  not  permit  of  giving  illustrations  of  results. 


CHAPTER  XXIV. 

EXTRACTION  OF  TEETH.^ 

The  primary  causes  which  lead  to  the  extraction  of  teeth  may  be 
summed  up  as  follows  : 

1.  The  ravages  of  dental  caries  that  are  beyond  repair. 

2.  Diseases  of  the  alveolar  process :  viz.,  tumors,  pyorrhea  alve- 
olaris,  alveolar  abscess,  etc. 

3.  Irregular  position  of  the  teeth.  This  will  include  cases  which 
require  removal  of  the  teeth  preparatory  to  correction  of  deformity 
of  the  jaw-bone. 

4.  Impaction  of  the  teeth. 

5.  Accidents  to  the  teeth  or  their  surrounding  structures. 

These  various  indications  hold  good  for  permanent  as  well  as  for 
temporary  teeth.  The  extraction  of  temporary  teeth  is  indicated  when 
they  are  so  affected  with  disease  that  they  cannot  be  restored  arti- 
ficially; a  simple  inflammation  of  the  pulp  should  never  be  the  reason 
for  its  extraction.  The  irrational  extraction  of  temporary  teeth  fre- 
quently causes  iregularities  of  the  coming-in  permanent  set,  which 
cannot  be  corrected  by  future  treatment   (Fig.  250). 

Before  undertaking  the  extraction,  the  field  should  be  cleaned, 
and  adhering  deposits  are  to  be  removed.  The  painting  of  the  soft 
structures  within  the  immediate  neighborhood  with  diluted  tincture  of 
iodin-  is  to  be  recommended.  If  a  forceps  is  used,  it  should  never 
engage  the  soft  tissue ;  the  overhanging  soft  gum  tissue  should  be 
removed  with  a  knife  or  tissue  elevator  prior  to  the  extraction  proper. 
The  forceps  must  engage  the  tooth  firmly ;  both  combined  form  a  lever. 
The  extraction  should  be  carried  out  slowly  and  always  in  the  line 
of  least  resistance.  If  a  tooth  root  should  break,  an  effort  should 
be  made  to  remove  the  remaining  part  at  once ;  very  small  frag- 
ments left  in  a  non-infected  socket  may  eventually  become  absorbed  or 
thrown  off. 

The  instruments  employed  for  the  extraction  of  teeth  are  forceps, 
elevators,  screws,  and  in  different  cases,  the  chisel  and  mallet.  A 
very    large    variety    of    forceps    and    elevators    have    been    devised ; 


1  For  the  selection  of  the  types  of  forceps  and  elevators  presented,  and  for 
the  rules  to  be  followed  in  normal  extraction  of  the  individual  teeth,  we  are  in- 
debted to  Dr.  Hermann  Prinz. 

2Tincture  of  iodin,  1  part;  aceton,  2  parts.  This  combination  contains  about  2^! 
per  cent  iodin  and  is  especially  recommended  for  the  surface  sterilization  of  the  tissues 
of  the  oral  cavity  ;  it  dries  almost  momentarily.  » 

340 


EXTRACTION  OF  TEETH. 


341 


a  few  well-selected  instruments  will  suffice  for  all  but  very  extraordi- 
nary cases.  Dental  forceps  are  made  after  two  general  patterns : 
the  English,  or  knuckle  joint;  and  the  American,  or  interlocking  joint. 
The  English  pattern  of  forceps  is  to  be  preferred,  as  it  will  not  obstruct 
the  view  of  the  field  of  operation  and  is  not  so  liable  to  catch  the  soft 
tissues  of  the  lips. 


Fig.   314. 


Fig.    315. 


Fig.    317. 

Fig.  314. 
Fig.  315. 
Fig.  316. 
Fig.  317. 
teeth. 

Fig.  318. 
Fig.  319. 
Pig.   320. 


Fig.   318. 


Fig.   319. 


Fig.   320. 


Forceps  for  the  ten  anterior  upper  teeth. 

Right  and  left  upper  molar  forceps. 

Bayonet  root  forceps. 

Hawk-bill    forceps    adapted    to    the    removal    of    the    lower    ten    anterior 

Hawk-bill  forceps  for  lower  molars. 

Universal  forceps. 

Slender  bayonet  forceps  for  upper  roots. 


For  the  extraction  of  the  upper  ten  anterior  teeth, — viz.,  incisors, 
canines,  and  bicuspids. — one  single  forceps  is  usually  sufficient  (Fig. 
314).  The  upper  first  and  second  molars  require  a  special  forceps 
(Fig.  315)  for  either  side,  on  account  of  the  shape  of  the  roots.  For 
the  extraction   of  the  upper  third   molars    (Fig.    316),   a   heavy-pat- 


342 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


terned  root  forceps  is  well  adapted.  The  lower  ten  anterior  teeth  may 
be  readily  removed  with  one  forceps  of  the  general  shape  of  the 
hawk-bill  pattern  (Fig.  317).  For  the  lower  molars  on  either  side  a 
hawk-bill  forceps  with  suitable  modification  of  the  beak  (Fig.  318),  or 
a  universal  forceps  (Fig.  319)  may  be  employed.  Both  lower  third 
molars  may  frequently  be  removed  with  this  same  forceps;  however, 
an  elevator  is,  in  most  cases,  best  adapted  for  such  purposes.  The 
roots  of  all  the  upper  teeth  may  be  removed  with  a  forceps  which  is 
built  upon  the  principle  of  a  slender  bayonet  style  (Fig.  320).  For 
the  extraction  of  the  roots  of  the  lower  teeth,  the  same  forceps  (Fig. 
317)  which  is  employed  for  the  removal  of  the  lower  anterior  teeth 
may  be  used  with  advantage.  A  few  elevators  for  the  extraction 
of  upper  and  lower  stumps  or  misplaced  teeth  are  very  serviceable. 
Some  suitable  patterns  are  illustrated  in  Figs.  321  and  323.  A  most 
suitable  instrument  for  the  removal  of  an  impacted  lower  third  molar 
is  the  elevator  illustrated  in  Fier.  323. 


Fig.    321.  Fig.    322.  Fig.    323. 

Fig.   321.     Right  and  left  elevators  for  removing  stumps  of  lower  roots. 

Fig.   322.      Bit  of  universal  stump  elevator. 

Fig.   323.      Elevator  for  removing  impacted  lower  third  molars. 


Regarding  the  position  of  the  patient,  it  is  well  to  bear  in  mind 
that  the  light  on  the  field  of  operation  must  not  be  obstructed ;  conse- 
quently, the  patient  should  face  the  source  of  light.  For  the  removal 
of  the  upper  teeth,  the  patient  is  seated  on  a  high  chair,  head  leaning 
slightly  backward ;  while  for  operations  about  the  lower  teeth,  a  low 
chair  is  to  be  preferred.  The  operator  usually  stands  on  the  right 
side  of  the  patient,  the  right  hand  firmly  grasping  the  forceps,  while  the 
left  hand  is  employed  to  draw  the  soft  tissues  well  out  of  the  way.  In 
using  the  hawk-bill  forceps  for  lower  teeth  on  the  left  side  of  the 
mouth,  the  operator  should  stand  on  the  left  side,  slightly  in  front  of 
the  patient. 

When  under  ether,  the  extractions  are  made  in  the  recumbent  po- 
sition. 


EXTRACTION  OF  TEETH.  343 

In  applying  the  forceps  to  any  tooth,  one  beak  is  first  placed  on 
the  palatal  (or  lingual)  side.  The  tooth  is  then  grasped  by  slightly 
closing  the  handles  of  the  forceps,  and  the  instrument  is  pushed  up 
(or  down)  as  far  as  possible  under  the  gum.  The  sharp  edges  of  the 
beaks  may  be  pushed  even  slightly  under  a  weak  alveolar  process, 
and  a  firm  grasp  of  the  root  is  thereby  readily  obtained.  This  is 
of  especial  importance  in  the  extraction  of  teeth,  the  crowns  of  which 
have  been  weakened  by  decay.  If  the  forceps  grasp  the  crown,  it 
is  very  apt  to  be  crushed,  and  the  extraction  of  the  root  is  made 
difficult;  but  if  the  crown,  be  it  ever  so  delicate,  is  used  as  a  guide 
for  placing  the  edges  of  the  beak  well  down  on  the  neck  or  upper  part 
of  the  root,  success  in  extracting  the  root  is  more  likely  to  follow. 
An  effort  is  now  made  to  slightly  rotate  the  tooth,  or  slight  lateral 
motion  is  applied.  Rotation  of  the  single-rooted  teeth  is  usually  suc- 
cessfully accomplished,  while  the  molars  require  a  definite  lateral  mo- 
tion, usually  first  inward,  which  is  followed  by  an  outward  and  down- 
ward (or  upward)  movement.  Care  should  be  exercised  in  not  apply- 
ing too  much  force  laterally,  as  the  tooth  may  readily  break.  The 
extraction  of  teeth  is  not  a  matter  of  applying  crude  force;  delicate 
movements  of  the  whole  hand  governed  entirely  by  the  wrist  are  the 
essential  features  of  this  operation. 

The  above  armamentarium  is  very  small  compared  with  the  number 
of  kinds  of  instruments  that  have  been  devised  for  the  extraction  of 
teeth.  It  is,  however,  proper  to  state  that  one  pattern  of  forceps  may 
be  used  for  almost  every  extraction.  This  is  especially  the  case  when  a 
general  anesthetic  is  used ;  then  the  surgeon  can  go  back  and  extract 
roots  that  may  have  been  fractured.  One,  patterned  after  the  heavy 
bayonet  forceps  shown  in  Fig.  316,  is  very  useful  for  universal  appli- 
cation. 

REMOVAL  OF  THE  INDIVIDUAL  TEETH. 

The  removal  of  the  temporary  teeth  is  usually  accomplished  without 
much  difficulty.  Children  require  careful  handling;  kindness  and  per- 
suasion will  do  more  with  an  unruly  child  than  roughness  and  display 
of  temper.  The  root  forceps  and  the  elevator  are  the  usual  instru- 
ments employed  in  the  extraction  of  temporary  teeth.  In  deep  frac- 
tures of  the  root,  a  small  brass  wood-screw,  screwed  in  the  root  canal 
and  then  grasped  with  a  flat-nosed  plier,  is  often  extremely  serviceable. 
These  roots  must  be  extracted  without  lateral  motion  in  a  straight 
line  in  the  direction  of  the  long  axis  of  the  root.  The  upper  first 
bicuspid  breaks  more  often  than  any  other  tooth,  on  account  of  the 
often  thin,  flat  roots.  Usually  this  root  is  bifurcated  at  its  upper  half, 
and  consequently  it  should  not  be  rotated  during  the  process  of  re- 


344  SURGERY  OF  THE  ^lOUTH  AND  JAWS. 

moval.  The  canine  is  the  strongest  single-rooted  tooth  in  the  mouth, 
and  frequently  great  force  is  required  in  its  luxation.  Slight  rotation 
is  always  indicated  whenever  possible.  In  the  extraction  of  the  first 
and  second  molars  slight  palatine  and  buccal  motion  is  essential  for 
their  luxation ;  the  final  removal  should  take  place  in  a  downward  and 
outward  line.  The  third  upper  molars,  if  not  misplaced,  are  usually 
very  easy  to  extract.  The  mouth  should  not  be  opened  too  far ;  other- 
wise the  tightly  stretched  muscles  will  obliterate  the  field  of  vision. 
The  last  upper  molar  is  frequently  misplaced,  usually  posteriorly  or 
buccally,  and  its  roots  are  often  curved  posteriorly  and  frequently 
united  together.  However,  three — sometimes  four,  and  very  rarely 
five — slender  single  roots  may  be  present.  If  the  tooth  can  be  firmly 
engaged  by  the  beaks  of  the  forceps,  usually  no  difficulty  is  experienced 
in  its  removal  (very  slight  lateral  motion  is  essential,  and  it  should 
always  be  taken  out  in  the  direction  of  the  long  axis  of  the  crown). 
Under  no  condition  should  an  elevator  be  used  for  the  removal  of  this 
tooth,  as  the  maxillary  tubercle  will  very  readily  break  when  power  is 
brought  against  it.  If  the  tooth  fractures  at  the  neck,  it  is  often 
necessary  to  separate  the  roots  by  means  of  the  dental  engine  and  a 
fissure  bur  or  a  chisel  and  mallet ;  this  procedure  is  preferable  to 
trying  to  extract  all  of  the  roots  with  the  forceps  at  once,  which 
usually  results  in  crushing  them.  In  forcing  the  root  forceps  high 
up  into  an  alveolus  in  this  region,  special  care  is  necessary  to  prevent 
the  pushing  of  the  root  into  the  antrum. 

The  lower  incisors  and  canines  are  readily  removed  by  firmly 
grasping  them  in  the  hawk-bill  forceps  and  tilting  labially;  the  thin 
alveolar  process  on  the  labial  side  will  yield  to  pressure,  and  the  teeth 
can  be  taken  out  without  much  force.  The  lower  bicuspids  are 
loosened  by  a  slight  lateral  motion  and  by  slight  rotation.  They  are 
single-rooted,  and  consequently,  little  danger  of  fracturing  their  roots 
is  experienced.  To  extract  the  lower  molars  on  the  right  side,  the 
operator  stands  back  of  the  patient,  while,  when  operating  on  the  left 
side,  he  occupied  a  position  on  the  same  side,  slightly  toward  the 
front  of  the  patient.  The  lower  molars  usually  have  two  distinct  roots ; 
consequently,  these  teeth  cannot  be  rotated  in  their  sockets.  A  slight 
lateral  motion  is  possible,  although  a  heavy  external  and  internal 
oblique  bony  line  may  offer  much  resistance. 

Great  difficulty  is  frequently  associated  with  the  removal  of  the 
lower  third  molar  tooth.  If  the  tooth  is  normally  erupted, — if  it  is 
in  perfect  alignment  with  the  other  teeth, — it  is  easily  extracted  with 
the  forceps,  or  an  elevator  (Fig.  323).  The  roots  of  this  tooth  may  be 
separate,  but  more  often  they  are  united  in  a  cone ;  and  they  are  almost 
always  curved  posteriorly.     As  a  consequence,  the  movement  of  luxa- 


EXTRACTION  OF  TEETH.  346 

tion  should  be  antero-posteriorly  so  as  to  avoid  breaking.  If  the 
elevator  is  employed,  the  operator  places  himself  back  of  the  patient 
when  the  right  tooth  has  to  be  taken  out,  and  near  the  left  side  for 
the  extraction  of  the  left  tooth.  The  sharp  point  of  the  elevator  is 
inserted  between  the  second  and  third  molar,  the  flat  side  facing  the 
last  molar,  while  the  oval  side  is  placed  against  the  second  molar, 
which  acts  as  a  fulcrum.  The  point  is  pushed  downward  and  inward 
and  slightly  forward  between  the  teeth.  Forward  and  downward 
pressure  is  exerted  on  the  handle,  so  as  to  loosen  the  tooth  and  lift  it 
out  in  a  semicircle,  tilting  the  crown  toward  the  ramus  of  the  mandible. 
If  the  first  molar  is  missing,  it  is  well  to  place  a  wedge  between 
the  remaining  teeth,  so  as  to  prevent  the  possible  luxation  of  the 
second  molar.  This  wedge  may  be  cut  from  a  piece  of  soft  pine 
wood,  or  a  piece  of  softened  dental  modeling  compound  is  pressed 
into  the  space,  removed,  chilled,  trimmed,  and  replanted.  During  the 
extraction,  this  wedge  and  the  second  molar  are  held  in  place  by  the 
fingers  of  the  left  hand.  Before  making  an  attempt  at  removal  of  an 
impacted  lower  third  molar,  it  is  essential  to  cut  away  all  overlying 
gum  tissue  so  as  to  expose  the  crown  as  fully  as  possible.  All  over- 
hanging bone  structure  must  be  cut  away  with  chisels  or  burs;  other- 
wise the  tooth  is  sure  to  break,  or — in  rare  instances,  if  too  much  force 
is  employed  with  an  elevator  or,  more  so,  with  the  old  style  Physick's 
forceps — fracture  of  the  jaw  at  its  angle  may  take  place,  or  avulsion 
of  the  two  molars  may  occur.  The  x-ray  is  of  the  greatest  importance 
in  diagnosing  these  malposed  teeth.  In  rare  instances — viz.,  in  such 
cases  where  the  third  molar  has  assumed  a  horizontal  position  and 
is  pressing  against  the  second  molar  below  its  crown — it  is  advisable 
to  remove  the  second  molar.  When  this  source  of  irritation  is  re- 
moved, usually  no  further  disturbances  of  the  misplaced  molar  are  to 
be  expected,  as  there  is  now  sufficient  room  for  its  forward  movement. 
While  this  method  of  surgical  procedure  is  objected  to  by  some 
operators,  it  has,  nevertheless,  given  excellent  results  in  a  number  of 
cases,  which  otherwise  meant  serious  complications. 

IMPACTED  TEETH. 

A  tooth  is  spoken  of  as  being  impacted  when  its  eruption  is 
partially  or  wholly  obstructed  by  bone  or  by  some  other  teeth.  This 
may  occur  in  the  anterior  part  of  the  jaw,  when  the  crown  of  a  mis- 
placed tooth  impinges  against  the  root  or  crown  of  some  other  tooth. 
The  most  common  example  of  a  misplaced  tooth  is  an  upper  canine 
tooth  situated  in  the  palate.  Occasionally  a  permanent  tooth  remains 
impacted  because  its  preceding  deciduous  tooth  for  some  reason  fails 
to  be  thrown  off  (Fig.  340). 


346 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


The  teeth  that  are  most  frequently  impacted  are  the  third  molars, 
which,  in  most  instances,  is  probably  due  to  a  disproportion  between 
the  size  of  the  jaw-bone  and  the  dental  arch.  A  third  molar  may 
remain  entirely  buried  in  the  bone,  or  its  complete  eruption  may  be 
prevented  by  one  cusp  pressing  against  or  locking  under  the  crown  of 
the  second  molar   (Fig.  324). 

Indications  for  Treatment. — An  impacted  tooth  should  not  be 
removed  without  some  special  indication ;  such  a  tooth  might  erupt 
and  become  serviceable  after  the  superimposed  tooth  is  lost.  In  some 
cases,  such  as  neuralgia  or  an  infection  around  the  unerupted  tooth, 
the  indications  for  removing  an  impacted  tooth  are  very  evident.  In 
other  cases,  impacted  teeth  are  removed  on  account  of  some  symptoms 
present  that  might  or  might  not  be  dependent  upon  the  impaction,  but 
about  which  an  exact  diagnosis  cannot  be  made. 


Fig.  324.      Impacted  upper  third  molar. 

tooth  to  erupt.  The  third  plan  is  to  remove  the  impacted  tooth.  Re- 
moval of  the  obstructing  tooth  is  indicated :  if  the  latter  is  a  deciduous 
Treatment. — An  impacted  tooth  may  be  treated  in  one  of  three 
ways,  according  to  the  circumstances  of  the  individual  case.  One  is 
to  remove  the  obstructing  tooth,  thus  allowing  the  impacted  tooth  to 
erupt.  Another  plan,  applicable  in  cases  in  which  the  impacted  tooth 
belongs  to  the  anterior  part  of  the  arch,  is  to  move  the  obstructing 
tooth  or  teeth  by  orthodontic  appliances  and  to  allow  the  impacted 
tooth,  or  if  it  is  diseased  and  there  is  reason  to  believe  that  the  impacted 
tooth  will  become  serviceable.  Very  frequently,  in  the  case  of  an  im- 
pacted third  molar,  the  obstructing  second  molar  is  removed.  This 
may  be  primarily  because  of  the  difficulty  of  removing  the  third  molar, 
or  because  of  damage  that  the  second  molar  has  suflfered  from  pressure 


EXTRACTION  OF  TEETH.  347 

upon  its  root  by  the  third  molar.  Removal  of  the  second  molar  for 
impaction  of'  the  third  is  an  old  practice  and  often  a  very  good  one. 
Shifting  of  the  obstructing  teeth  is  indicated  in  young  persons,  when 
the  obstruction  is  due  to  a  contraction  of  the  dental  arch. 

Removal  of  an  Impacted  Tooth. — When  it  is  not  desirable  to 
remove  the  obstructing  tooth,  the  impacted  tooth  may  be  removed  in 
one  of  two  ways.  The  area  of  bone  beneath  which  the  impacted  tooth 
is  situated  is  exposed  by  turning  back  a  semilunar  flap  of  muco- 
periosteum,  with  its  base  toward  the  palate  or  toward  the  body  of 
the  jaw-bone.  It  is  customary  in  cutting  down  upon  a  tooth,  or 
foreign  body  in  any  part  of  the  body,  to  make  a  linear  incision 
directly  down  upon  the  object,  but  a  clearer  view  and  a  larger  oper- 
ative field  will  be  obtained  by  making  a  semilunar  cut  and  turning  back 
a  flap  that  will  freely  expose  a  sufficient  area  of  bone.  After  ex- 
posing its  neck,  the  tooth  may  be  cut  in  two  with  a  fine  drill  or  a  cross- 
cut fissure  bur.  After  doing  this,  it  is  usually  easy  to  remove  first 
the  crown  and  then  the  roots  with  forceps.  Sectioning  of  a  tooth, 
especially  a  canine,  is  frequently  a  tedious  process,  and  it  is  usually 
a  much  quicker  operation  to  remove  the  thinner  layer  of  superimposed 
bone  and  lift  the  tooth  out  somewhat  laterally.  This  can  be  done  by 
the  use  of  small  gauges  and  bone  burs,  but  an  equally  or  more  satis- 
factory operation  can  be  done,  often  in  a  few  minutes,  by  removing 
the  bone  from  over  the  full  length  of  the  root  with  a  few  bold  strokes 
with  a  fair-sized  grooved  chisel.  In  many  instances,  an  impacted  third 
molar  can  be  removed  with  a  suitable  elevator  after  carving  out  a 
cavity  above  in  the  base  of  the  ramus,  but  if  an  anterior  cusp  is  locked 
within  the  constriction  of  the  neck  of  the  second  molar,  then  the 
excavation  in  the  ramus  must  extend  beyond  the  apices  of  the  roots, 
before  the  engaged  cusp  can  be  liberated. 

After-treatment. — After  removing  an  impacted  tooth,  if  the  re- 
maining space  is  large,  it  may  be  filled  with  a  light  packing  of  iodoform 
gauze,  which  may  also  be  placed  under  a  semilunar  flap.  This  will 
control  hemorrhage.  This  packing  may  be  removed  in  one,  two,  or 
three  days,  after  which  no  special  treatment  is  required.  If  a  large 
piece  of  the  alveolar  process  is  broken  loose,  this  should  be  pushed 
back  into  place. 

If  the  antrum  is  freely  opened,  in  the  extraction  of  an  upper  molar, 
it  might  be  washed  out  with  saline  solution  for  a  few  days  afterwards. 


CHAPTER  XXV. 

INFECTIONS  AND  INFLAMMATIONS  OF  THE  MOUTH. 

The  question  arises  whether  a  systematic  review  of  the  diseases  of 
the  mouth  should  be  presented  in  a  work  on  surgery ;  but  as  many  of 
them  are  best  treated  by  surgical  means  and  any  one  of  them  may 
influence  a  surgical  result,  v/e  do  not  believe  the  best  work  can  be  done 
without  at  least  the  ability  to  recognize  the  various  lesions  that  may 
appear,  even  though  many  of  them  are  strictly  non-surgical.^ 

The  mouth  is  subject  to  a  great  number  of  diseases,  some  of  which 
are  purely  local,  while  others  are  local  manifestations  of  a  general 
disorder.  However,  even  among  the  diseases  that  are  caused  by  local 
infections,  there  are  very  few  but  what  are  more  or  less  dependent 
upon,  or  are  influenced  by,  the  state  of  the  digestion  or  metabolism  of 
the  individual. 

The  close  relation  that  exists  between  diseases  of  the  digestive  tract 
and  irritations  of  the  mouth  is  probably  explained  by  the  fact  that  toxins 
absorbed  from  the  stomach  and  intestines  are  partially  excreted  in  the 
saliva,  and  that  much  of  the  septic  material  of  the  mouth  finds  it  way 
to  the  stomach  and  intestines. 

It  is  not  too  much  to  assume  that  every  disease  has  one  or  more 
specific  causes.  Those  of  which  the  cause  is  known  are  classified 
accordingly.  At  present  there  are  still  many,  recognized  only  through 
their  symptoms,  and  these,  like  tumors,  have  to  be  classified  according 
to  their  lesions.  This  symptomatic  arrangement  is  far  from  satisfac- 
tory; for  in  some  instances  the  changing  complex  carries  a  case  from 
one  classification  into  another.  The  result  is  that  in  some  instances  a 
number  of  different  affections  are  placed  under  the  same  heading,  while 
in  others  the  different  clinical  manifestations  of  the  same  disease  are 
called  by  as  many  different  names.  Because  our  clinical  practice  does 
not  always  keep  pace  with  our  knowledge,  different  diseases  with 
known  causes  may  still  be  grouped  under  one  heading,  if  their  symptoms 
are  somewhat  similar.  Thus,  we  still  find  it  convenient  to  speak  of  a 
phlegmonous  stomatitis,  referring  to  certain  symptoms  that  we  know 
are  produced  by  some  kind  of  a  pus-producing  organism,  in  spite  of 
the  fact  that  it  is  possible  in  almost  every  instance  to  determine  the 
exact  nature  of  the  infection  by  a  microscopical  examination. 

^In  writing  this  chapter,  we  have  consulted  several  of  our  friends  who  also 
have  frequent  opportunities  to  observe  mouth  lesions.  We  have  drawn  upon 
Butlln,  Bruck,  and  Pfaundler  and  Schlossman,  as  well  as  upon  our  own  obser- 
vations. 

348 


INFECTIONS  OF  THE  MOUTH.  349 

A  strict  categorical  arrangement  of  mouth  lesions  is  not  easy  to 
make,  and  if  the  plan  were  followed  to  its  ultimate  possibilities,  the 
attempt  might  land  one  in  the  predicament  of  the  man  who  differ- 
entiated 97  varieties  of  pemphigus. 

In  the  following,  all  diseases  known  to  be  due  to  a  specific  infection 
are  classified  accordingly,  but  the  various  recognized  symptoms  that 
appear  without  recognized  cause,  or  which  we  know  may  be  due  to  one 
of  a  number  of  causes,  are  classified  according  to  the  most  prominent 
characteristic  of  the  lesion. 

STOMATITIS. 

Acute  Catarrhal  Stomatitis. — Under  this  head  should  be  in- 
cluded all  acute  inflammations  of  the  mouth,  characterized  by  simple 
redness  and  soreness  of  the  mucous  membrane.  They  may  be  caused 
by  the  irritation  of  cutting  teeth,  by  thermic  or  chemical  irritants,  by 
spices,  alcohol,  or  tobacco,  or  by  disturbances  of  the  digestion,  or 
metabolism.  They  may  be  but  a  local  manifestation  of  some  general 
disease,  drug  or  mineral  poisoning — such  as  mercury,  lead,  or  iodin. 

As  a  rule,  a  dusky-red  color  precedes  an  indistinct  grayish-white 
filmy  discoloration  due  to  cloudy  swelling  of  the  epithelium.  After 
desquamation,  the  mucous  membrane  remains  intensely  red.  The  pa- 
tient complains  of  discomfort,  especially  on  eating  hot  or  spiced  foods, 
and  this  may  be  a  reason  for  children  refusing  to  eat  or  nurse. 

The  sense  of  taste  is  diminished,  and  the  tongue  is  furred.  The 
flow  of  saliva  is  usually  increased,  but  the  mucous  membrane  may  be 
rather  dry.  The  whole  mouth  may  be  affected,  or  it  may  be  limited 
to  the  gums,  the  neighborhood  of  the  oval  or  lingual  tonsils,  or  to 
some  other  part. 

The  prognosis  will  depend  entirely  upon  the  cause.  Most  cases 
heal  quickly  without  treatment,  while  others  may  go  on  to  a  chronic 
form.  The  latter  are  dependent  upon  some  persistent  defect  in  the 
digestion  or  metabolism,  or  some  other  continuous  irritation. 

The  treatment  consists  in  control  of  the  cause,  abstinence  from 
irritating  foods,  possibly  the  administration  of  a  purge,  attention  to  the 
digestion,  and  the  use  of  some  alkaline  wash,  such  as  the  alkaline  anti- 
septic solution  (N.  F.),  diluted  with  three  parts  water. 

In  bottle-fed  infants,  special  care  should  be  given  to  the  cleanliness 
of  bottles  and  nipples. 

Method  of  Washing  a  Baby's  Mouth. — The  proper  method  of 
applying  a  lotion  to  a  baby's  mouth  is  a  matter  of  importance.  It  is 
questionable  if  the  prevalent  practice  of  daily  washing  babies'  mouths 
is  necessary  or  even  commendable.  If  a  lotion  is  to  be  applied  to  a 
baby's  mouth,  it  should  be  done  as  follows : 


350  SURGERY  OF  THE  MOUTH  AND  JAWS. 

The  infant  is  turned  face  downward  on  the  nurse's  lap.  The  finger 
of  the  nurse,  covered  with  cotton  which  is  wet  with  the  lotion,  is 
placed  in  the  baby's  mouth,  and  he  is  allowed  to  champ  upon  it.  In 
this  way  no  mechanical  damage  will  be  done.  It  is  needless  to  say  that 
the  medicament  should  not  be  poisonous.  If  the  baby  objects,  the 
solution  may  be  sweetened. 

Chronic  Stomatitis. — This  is  often  found  in  persons  who  neglect 
their  teeth,  especially  users  of  alcohol,  tobacco,  and  overspiced  or  over- 
heated food. 

The  affected  part  of  the  mucous  membrane  is  usually  somewhat 
drier  than  normal,  in  some  cases  so  dry  as  to  cause  discomfort  and 
difficulty  in  swallowing.  It  may  be  slightly  infiltrated  or  atrophied ;  in 
the  latter  case  the  dilated  blood  vessels  will  be  apparent.  There  may  be 
salivation  or  disturbance  in  taste. 

Chronic  stomatitis  is  very  resistant  to  treatment.  Often  little  can 
be  done  toward  a  permanent  cure.  The  symptoms  can  be  relieved  by 
the  withdrawal  of  the  irritants,  the  use  of  an  alkaline  antiseptic  mouth 
wash,  and  the  occasional  painting  of  the  affected  areas  with  a  2  per 
cent  silver  nitrate  solution. 

Chronic  or  subacute  gingivitis  arising  during  pregnancy  usually 
subsides  at  time.  Leucoplakia  may  arise  in  any  part  of  the  mouth,  but 
is  most  common  in  the  tongue  (see  ;p.  529).  (For  septic  or  phleg- 
monous stomatitis,  see  p.  416.) 

Exudative  stomatitis  is  characterized  by  the  formation  of  serous, 
seropurulent,  or  hemorrhagic  blebs  or  bullae,  or  by  a  fibrinous  exudate. 
An  eruption  of  vesicles  occurs  in  herpes  and  pemphigus,  after  scalds 
or  burns,  erysipelas  or  a  mouth  disease,  or  smallpox  and  chicken-pox. 
while  a  local  fibrinous  exudation  may  among  other  causes  be  due  to 
the  staphylococcus  or  the  streptococcus. 

Herpes. — Among  tlie  causes  enumerated  are  digestive  disorders 
and  some  acute  infections,  such  as  coryza,  grippe,  pneumonia,  malaria, 
epidemic  cerebrospinal  meningitis,  etc.  In  some  cases  the  eruption 
comes  without  any  assignable  cause ;  in  some  it  accompanies  specific 
fever;  in  others,  some  digestive  disturbance;  while  alcohol  seems  also 
to  be  a  causative  factor.  Recurrent  herpes  of  the  tip  of  the  tongue 
is  seen  in  syphilitics.  Regardless  of  the  cause,  herpes  of  the  face  and 
mouth  seems  to  be  a  trophoneurosis  of  the  fifth  nerve. 

It  has  its  counterpart  in  the  herpes  zoster  that  is  distributed  over  the 
course  of  an  inflamed  nerve  in  other  parts  of  the  body.  The  lesion 
consists  of  a  crop  of  vesicles  varying  from  the  size  of  a  pinhead  to 
almost  any  size.  They  occur  most  frequently  on  the  lips,  often  in 
conjunction  with  herpes  of  the  face,  but  they  may  come  on  the  inside 
of  the  cheek  or  on  the  tongue,  palate,  or  pharynx.     The  vesicles  always 


INFECTIONS  OF  THE  MOUTH.  351 

occur  in  clusters,  and  their  appearance  is  often  accompanied  by  fever. 
At  first  the  content  of  the  vesicles  is  a  clear  fluid,  but  later  it  becomes 
turbid.  On  the  lips  and  face  they  tend  to  dry  up  in  a  few  days,  leaving 
little  crusts  which  are  renewed  when  disturbed.  In  the  mouth  the 
vesicles  always  burst  early.  The  covering  of  the  vesicle  forms  a 
pellicle  which  can  be  detached,  leaving  a  small  circular  excavation, 
which  is  at  first  blood-stained  and  later  becomes  yellow.  They  are 
surrounded  by  a  well-marked  red  zone.  The  pellicle  is  composed  of 
the  corneous  layers  of  the  epithelium,  thickened  by  infiltration. 

Herpes  of  the  lip  gives  but  little  discomfort,  but  herpes  within  the 
mouth  may  be  accompanied  by  great  pain,  which  is  worse  during  the 
act  of  eating.  In  most  cases  an  attack  lasts  but  a  few  days,  but 
especially  in  the  mouth,  it  may  have  a  marked  tendency  to  recur. 
Rarely  it  is  both  persistent  and  painful  and  may  be  the  cause  of  ill 
health  from  pain,  loss  of  sleep,  and  lack  of  food.  Most  cases  require 
little  treatment.  A  soothing  lotion  or  ointment  may  be  applied.  Butlin, 
acting  upon  the  theory  that  recurrent  cases  were  due  to  an  infection, 
uses  an  active  antiseptic  treatment  from  which  he  has  obtained  the 
best  of  results.  In  one  persistent  case,  accompanied  by  great  pain, 
he  had  the  parts  thoroughly  dried,  and  then,  with  a  clean,  soft  rag,  a 
mixture  of  carbolic  acid,  spirits  of  chloroform,  tincture  of  myrrh,  and 
cologne  water  was  rubbed  into  the  surface  frequently.  The  pain  of 
the  first  few  applications  might  be  relieved  by  previously  painting  the 
surface  with  a  weak  cocain  solution.  If  the  benefit  from  this  applica- 
tion is  due  entirely  to  its  antiseptic  value,  the  same  result  might  be 
obtained  from  a  2  per  cent  solution  of  silver  nitrate  or  chromic  acid, 
or  a  10  per  cent  formol  solution.-  Though  a  most  powerful  and  at  the 
same  time  a  penetrating  antiseptic,  its  application  to  a  raw  surface  is 
rarely  justified  without  a  previous  application  of  cocain. 

Butlin  refers  to  good  results  in  one  severe  case  from  rubbing  in 
an  ointment  of: 

Cocain,  gr.  v. 

Boric  acid,  gr.  x. 

Vaselin,  3ii. 

Lanolin,  3vi. 
The  tongue  is  dried  before  each  application.     This  can  hardly  be  con- 
sidered an  actively  antiseptic  preparation. 

Pemphigus. — It  is  not  known,  when  occurring  in  the  mouth, 
whether  this  is  a  pure  trophoneurosis  or  an  infection.  Clinically,  a 
number  of  lesions  on  various  parts  of  the  body,  characterized  by  the 
formation  of  large  bullae,  is  called  pemphigus.     According  to  Crocker, 


2  A  10  per  cent  formalin  solution  is  a  4  per  cent  solution  of  formaldehyde,  which 
Is  made  by  adding  one  part  of  formalin  or  formol  to  nine  of  water. 


352  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Martins  made  as  many  as  97  varieties  and  subdivisions.  Under  these 
headings  must  have  been  included  a  number  of  different  diseases  and 
infections.  It  appears  generally  in  the  mouths  of  middle-aged  or 
elderly  persons  and  first  shows  itself  in  the  form  of  bullae,  which  often 
escape  observation.  On  the  soft  palate  or  cheek,  not  so  frequently  on 
the  tongue,  there  are  seen  grayish  or  yellowish  excoriations  with  the 
pellicle  of  bursted  epithelium  still  clinging  to  them.  There  is  salivation, 
pain  on  swallowing,  and  an  abominable  fetor.  The  lesions  heal  without 
scar  and  have  a  tendency  to  recur.  Elderly  persons  may  be  very  much 
depressed  by  the  disease.  The  local  treatment  is  similar  to  that  of 
herpes. 

Aphthous  Stomatitis  or  Mucolofibrinous  Stomatitis. — ^The  latter 
term  is  proposed  by  Pfaundler  and  Schlossman,  as  a  contraction  for 
Frankel  and  Krause's  more  elaborate  one  of  stomatitis  fibrinosa  macu- 
losa disseminata,  because  the  word  aphthae  simply  means  inflamed,  and 
the  term  has  in  the  past  been  applied  to  a  variety  of  lesions.  Aphthae 
is  now  recognized  as  a  contagious  disease.  It  comes  with  fever  and 
appears  as  spots  or  plaques,  varying  in  size  from  a  pinhead  to  a  pea. 
They  are  at  first  vividly  red  and  later  somewhat  whitish  or  yellowish, 
and  are  surrounded  by  a  red  area  of  infiltration.  They  appear  in 
various  parts  of  the  mouth,  especially  in  the  vestibule,  fornices,  and 
floor.  In  some  cases  the  more  posterior  parts  of  the  mouth  and  ton- 
sils are  affected.  The  spots  may  be  scanty,  or  very  numerous  and 
multiply  themselves.  They  form  several  crops  and  have  a  tendency  to 
coalesce.  The  eruption  is  not  vesicular,  but  is  from  the  first  onset  a 
fibrinous  exudation,  which  is  deposited  within  the  epithelium  itself.  The 
plaques  increase  for  the  first  three  days  and  are  accompanied  by  sali- 
vation and  considerable  pain.  The  neighboring  lymph  nodes  become 
enlarged,  and  there  is  a  decided  fetor.  The  exudate  then  shrinks  and 
is  discharged,  leaving  red  spots,  which  gradually  disappear,  leaving 
no  scar. 

The  treatment  consists  in  fresh  air,  administering  to  the  comfort 
of  the  patient,  proper  feeding,  attention  to  the  digestive  tract,  and  the 
use  of  an  alkaline  antiseptic  mouth  wash. 

Infants  may  be  given  a  teaspoonful  of  a  3^  per  cent  solution  o,f 
potassium  chlorate  every  two  hours.  In  persistent  cases  the  spots 
should  be  touched  with  a  2  per  cent  solution  of  silver  nitrate  once  or 
twice  a  day.  The  attack  may  be  severe,  and  the  patient  may  have  con- 
siderable depression. 

Pellagra. — Pellagra  is  accompanied  by  a  chronic  stomatitis  in 
most  cases.  Pellagra  is  characterized  by  a  chronic  sunburn-like  derma- 
titis on  the  hands  and  face,  most  cases  showing  a  definite  pigmentation. 
It  is  accompanied  by  diarrhea,  general  weakness,  and  mental  symp- 


INFECTIONS  OF  THE  MOUTH.  353 

toms,  varying  from  melancholia  to  mania.  It  lasts  from  months  to 
years,  showing  acute  exacerbations  in  spring  and  fall,  and  at  present 
usually  terminates  fatally. 

Fordyce's  disease  is  the  name  given  to  a  distention  of  the  sebaceous 
follicles  which  occur  on  the  mucous  surfaces. 

Erythema  multiforme  also  occurs  in  the  mouth. 

Lichen  Planus.— The  eruption  in  the  mouth  consists  of  plaques 
which  appear  in  the  form  of  white  dots,  of  patches  and  streaks,  or 
of  a  white  milky  network.  In  some  instances  the  plaques  are  dis- 
crete, and  in  others  tmited  by  an  indurated  base.  It  is  most  common 
on  the  flexor  sides  of  the  forearms,  lower  abdomen,  waist,  calves, 
ankles,  and  mucous  membrane.  Hardaway  states  that  it  never  occurs 
on  the  face.  When  it  occurs  in  the  mouth,  it  has  been  confused  with 
leucoplakia  (see  p.  531). 

Bednar's  Aphthae. — This  name  has  been  given  to  certain  usually 
definitely  localized  excoriations  of  the  posterior  part  of  the  hard  palate 
of  infants,  which  become  covered  with  a  fibrinous  exudate  due  to  a 
pus  infection.  The  lesion  usually  consists  of  larger  or  smaller  sym- 
metrically placed  ulcers,  situated  on  each  side  of  the  posterior  part 
of  the  hard  palate.  Between  these  there  is  often  a  long,  narrow  ulcer- 
ation corresponding  to  the  median  raphe.  The  two  laterally  placed 
ulcers  may  join  the  median  longitudinal  one,  giving  the  general  outline 
of  a  butterfly  with  outspread  wings.  However,  the  shape  and  location 
of  the  lesion  is  accidental,  and  similar  ulcers  might  be  produced  in  any 
part  of  the  mouth.  It  may  result  from  mechanical  efforts  at  cleansing 
the  mouth. 

The  destruction  of  the  epithelium  is  due  to  a  necrosis  which  opens 
both  lymph  and  blood  vessels.  This  may  open  the  way  to  a  general 
infection.  In  infants  with  a  single  cleft  palate  who  have  been  allowed 
to  champ  on  a  nipple,  it  is  rather  common  to  see  a  long  yellow  streak 
on  the  oral  part  of  the  nasal  septum,  from  the  habitual  use  of  a  pacifier 
or  a  nipple  that  rests  against  the  hard  palate. 

Treatment  consists  in  the  withdrawal  of  the  irritant  and  in  painting 
the  ulcers  daily  with  a  3  per  cent  silver  nitrate  solution.  Cure  usually 
results  in  a  few  days. 

Mineral  Poisons. — Mercurial  stomatitis  is  the  most  common  of 
the  toxic  inflammations  of  the  mouth,  Bismuth  poisoning  will  produce 
a  similar  condition,  while  phosphorus  produces  a  periostitis  that  may 
later  involve  the  mucous  membrane.  (See  Mineral  Poisons,  Chap. 
XXVI.) 

The  mercury  may  have  been  taken  in  the  form  of  calomel  as  a 
purge;  or  for  the  treatment  of  syphilis;  or  may  have  been  inhaled  in 
certain  occupations.     Some   persons   are  much   more  liable  to   show 


354  SURGERY  OF  THE  MOUTH  AND  JAWS. 

toxic  symptoms  than  are  others.  There  is  an  increased  salivation,  the 
saliva  containing  mercury.  A  stomatitis  follows,  first  occurring  around 
the  gingivae,  accomi^anied  by  an  irritation  of  the  root  membrane. 

It  may  go  on  to  ulceration,  gangrene  of  the  soft  tissues,  loss  of  teeth, 
and  necrosis  of  the  bone.  It  rarely  if  ever  occurs  except  when 
teeth  are  present,  and  is  much  more  liable  to  occur  when  the  teeth 
are  decayed  or  the  gingivae  are  irritated  by  tartar.  The  salivation 
and  fetor  may  be  very  pronounced. 

The  mucous  membrane  of  the  gums,  sides  of  tongue,  and  floor 
may  present  shallow  irregular  ulcers  that  have  somewhat  the  same 
character  as  those  seen  in  stomatocace. 

The  diagnosis  is  made:  on  the  appearance  of  the  mouth;  the  history 
of  the  administration  of  mercury  or  the  exposure  to  the  fumes  of  mer- 
cury; and  where  it  is  a  matter  of  sufficient  interest,  the  demonstration 
of  the  presence  of  mercury  in  the  saliva. 

GANGRENE  (SLOUGH). 

Sloughing  is  caused  by  some  interference  with  the  circulation. 
Within  the  mouth  it  may  follow  mechanical  pressure,  but  is  more  apt 
to  occur  when  the  tissues  pressed  upon  become  infected.  The  mineral 
poisons,  mercury  and  bismuth,  cause  sloughing,  as  may  certain  infec- 
tions.    Within  the  mouth  the  gangrene  is  necessarily  moist. 

Gangrene,  or  slough,  is  the  death  of  tissue,  and  the  extent  of  the 
slough  will  correspond  to  the  area  in  which  the  circulation  becomes  per- 
manently blocked.  If  the  agent  of  injury  acts  on  a  certain  limited  area, 
the  slough  will  not  extend  beyond  this  area.  An  example  of  this  is 
the  death  of  tissue,  due  to  pressure  of  a  lead  plate,  or  of  tight  sutures. 
Only  that  tissue  will  die  which  is  pressed  upon  by  the  plate  or  sutures. 
This  is  a  self-limited  gangrene.  A  transplanted  flap  with  an  insuffi- 
cient circulation  gives  another  example  of  the  self-limited  gangrene.  If 
the  agency  or  injury  is  progressive,  then  the  area  of  gangrene  may 
extend  accordingly.  This  constitutes  a  spreading  gangrene.  A  spread- 
ing gangrene  is  usually  due  to  some  infection,  but  an  infection  may 
cause  only  a  limited  gangrene. 

In  a  limited  gangrene  the  slough  is  early  separated  from  the  live 
tissue  by  a  sharp  line  of  demarcation.  The  dead  area  first  becomes 
a  darker  color  and  then  bluish  or  purplish.  Later  this  changes  to  a 
slate  color,  and  as  decomposition  progresses,  the  slough  turns  a  light 
yellowish  gray.  A  progressive  gangrene,  due  to  a  spreading  infection, 
will  show  no  sharp  line  of  demarcation  and  as  it  extends  will  show  all 
stages  of  putrefaction.  After  the  second  day,  there  is  always  a  foul 
odor,  and  if  the  gangrene  is  of  any  considerable  extent,  an  acrid  dis- 
charge. 


INFECTIONS  OF  THE  MOUTH.  355 

Treatment. — A  limited  gangrene  needs  no  special  treatment. 
The  dead  tissue  will  separate  spontaneously,  but  when  the  sloughs 
are  large,  they  may  be  removed  close  to  the  live  tissue  with  scissors. 
A  peroxid  of  hydrogen  or  permanganate  of  potassium  mouth  wash 
will  help  to  control  the  odor.  In  a  progressive  infectious  gangrene, 
active  measures  must  be  adopted  to  overcome  the  infection;  these  may 
include  the  destruction  of  a  certain  amount  of  healthy  tissue  around 
the  diseased  area. 

NOMA  (CANCRUM  ORIS). 

This  is  a  progressive  gangrene  of  the  mouth,  which  is  most  apt 
to  occur  in  children,  especially  young  girls  between  the  ages  of  three 
and  twelve  years,  though  it  also  occurs  in  adults.  It  is  usually  seen 
in  debilitated  subjects  and  most  often  follows  some  infectious  disease, 
such  as  measles,  whooping  cough,  typhoid,  or  tuberculosis,  or  the 
mercurialization  of  syphilitic  children.  A  specific  cause  has  not  been 
demonstrated.  There  has  been  some  evidence  presented  that  would 
suggest  that  noma  is  due  to  the  blocking  of  the  circulation  by  the 
invasion  of  the  tissue  with  the  same  spirochete  that,  with  Bacillus 
fusiformus,  causes  Vincent's  angina  and  possibly  ulcerative  stomatitis. 
In  certain  epidemics  an  apparent  relationship  to  diphtheria  was  thought 
to  be  observed.  A  bacillus  closely  resembling  the  Klebs-Lofifler 
bacillus,  which  is  the  cause  of  diphtheria,  has  been  demonstrated  in  the 
lesions,  but  as  far  as  we  know,  diphtheria  antitoxins  have  never  shown 
any  curative  effect. 

It  has  been  observed  to  originate  in  an  indurated  spot,  usually  near 
the  lips.  This  becomes  dark,  soon  softens,  and  breaks  down.  The 
ulcer  spreads,  and  sooner  or  later  it  involves  the  full  thickness  of  the 
cheeks.  The  gums  may  be  involved,  exposing  the  bone,  but  the  tongue 
is  rarely  attacked.  A  very  early  perforation,  in  which  the  outer  surface 
of  the  cheek  is  involved  to  the  same  extent  as  the  inner,  has  been 
regarded  as  a  favorable  symptom,  but  it  does  not  always  mean  that 
the  sloughing  process  has  ceased.  Other  such  spots  may  appear,  even 
when  the  primary  slough  has  become  limited.  After  perforation  of 
the  skin  the  cheek  may  become  somewhat  edematous,  but  remains  pale. 
The  process  usually  spreads  rapidly,  and  before  death  occurs,  it  may 
have  involved  the  tissue  to  the  forehead  and  neck,  leaving  a  black 
stinking  mass  of  putrefying  flesh,  with  the  teeth  falling  out  and  the 
bones  exposed   (Fig.  325). 

The  lymphatic  nodes  are  early  involved,  and  though  the  temperature 
is  nearly  always  high,  the  child  for  some  time  shows  little  signs  of  sub- 
jective disturbances,  save  for  languor.  Death  from  sepsis  or  pneu- 
monia usually  results  in  a  few  days.     The  diagnosis  is  easily  made 


356 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


after  the  first  few  hours.  The  gangrene  seldom  stops  spontaneousl_y. 
When  death  does  not  result,  the  scarring  will  be  proportionate  to  the 
extent  of  the  tissue  destruction.  There  may  be  only  a  slight  stellate 
scar  or  a  horrible  deformity.  Noma  also  appears  upon  the  vulva  and 
around  the  anus. 

Treatment. — The  whole  diseased  area  should  be  destroyed  well 
into  the  healthy  tissue  with  an  actual  cautery,  and  to  the  remaining 
scar  may  be  applied  a  10  per  cent  solution  of  formalin  at  the  time  of 
operation,  and  as  often  afterward  as  is  practical.     Formaldehyde  is  a 


Fig.   325.      Noma.      A  piece  has  been  removed   from  the   left  cheeli   for  examination. 
Photographed  for  this  book  by  courtesy  of  the  curator  of  the  Hunterian  Museum,  London. 


powerful  and  penetrating  antiseptic — much  more  so  than  alcohol, 
which  has  been  recommended  for  this  purpose.  If  it  is  true  that  noma 
is  caused  by  the  same  agency  that  causes  Vincent's  angina,  then,  by 
analogy,  the  frequent  application  of  methylene  blue  to  the  raw  surfaces 
and  to  the  mouth,  after  operation,  might  be  beneficial.  Excision  of 
the  gangrenous  area  with  a  knife  with  immediate  suture  has  been 
practiced,  but  the  results  are  very  bad  with  either  treatment.  If  the 
patient  survives,  some  sort  of  a  plastic  operation  will  usually  be  in- 
dicated. 


INFECTIONS  OF  THE  MOUTH.  357 

SPECIFIC  INFECTIONS. 

Measles.— Measles  show  Koplik's  and  Rehn's  spots.  The  for- 
mer appear  as  white  specks,  the  size  of  a  pin  point,  surrounded  by  a 
narrow  red  areola.  They  are  seen  only  by  daylight  situated  on  the 
buccal  mucous  membrane  opposite  the  molar  teeth.  Later,  as  the 
case  advances,  the  white  specks  disappear,  and  the  areolae  coalesce,  leav- 
ing a  red  area.  Rehn's  spots  are  situated  on  the  hard  and  soft  parts 
of  the  palate  and  resemble  the  measle  rash  in  the  skin.  The  tongue 
is  furred. 

German  Measles  (Rubeola). — Carr  and  Orcheimer  describe  red 
spots  appearing  on  the  uvula  the  first  day,  but  not  on  the  hard  palate. 

Scarlatina. — Besides  the  scarlet-red  swollen  pharynx,  tonsils, 
and  velum,  scarlatina  presents  a  punctate  red  rash  on  the  hard  palate. 
The  tongue  on  the  fourth  day  after  the  onset  presents  the  so-called 
"strawberry"  appearance,  due  to  the  prominence  of  the  dark-red  fili- 
form papillae. 

Variola  and  Varicella. — In  smallpox  and  chicken-pox  the  eru]i- 
tion  may  appear  on  the  palate  at  the  same  time  as  it  appears  on  the 
skin.  Though  it  is  of  the  same  character,  the  umbilicated  vesicles 
soon  rupture  and  leave  in  their  place  shallow  ulcers,  from  which  are 
seen  hanging  shreds  of  the  pellicle. 

Scurvy. — This  is  a  disease  that  is  only  occasionally  observed  at 
the  present  day ;  though  in  the  days  when  the  crews  of  sailing  ship? 
were  often  liable  to  long  periods  of  a  diet  of  "salt  horse,"  dried  fish, 
and  Liverpool  "pan-tiles,"  scurvy  was  not  at  all  uncommon.  It  seems 
to  depend  for  its  development  upon  the  lack  of  fresh  vegetables  and 
fruit,  coming  most  commonly  with  a  continued  diet  of  salt  meat,  fish, 
and  bread.  It  is  not  improbable  that  it  is  due  to  some  infection.  The 
most  characteristic  symptoms  are  malaise,  a  petechial  skin  eruption 
which  is  not  elevated  and  which  turns  brown,  indistinct  swellings  along 
the  shafts  of  long  bones  due  to  subperiosteal  effusions,  and  a  condition 
of  the  gums  described  below. 

A  characteristic  condition  of  the  mouth  is  almost  constant  in  scurvy. 
The  gums  become  swollen,  spongy,  and  detached  from  the  teeth,  be- 
yond which  they  project  in  loose  purplish  masses  that  sometimes 
ulcerate.     The  teeth  become  loose,  and  the  breath  is  fetid. 

According  to  Buzzard,  in  the  absence  of  teeth,  either  from  a  part  of 
the  mouth  or  in  toothless  infants  or  old  persons,  these  changes  do  not 
occur,  but  the  gums  only  are  pale. 

The  local  treatment  is  similar  to  that  employed  in  stomatitis.  The 
general  treatment  consists  in  fresh  air,  fresh  vegetables,  and  fruits — 
for  infants,  raw  milk. 

Loose  teeth  may  be  protected  by  interdental  splints. 


358  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Gonorrhea. — Gonorrhea,  apparently,  occasionally  occurs  in  the 
mouths  of  new-born  infants — rarely  in  adults.  The  mucous  membrane 
is  swollen  and  red,  and  in  places  there  occur  superficial  ulcerations. 
The  secretions  are  said  to  show  the  presence  of  the  gonococcus,  and  a 
purulent  stomatitis  in  the  newly  born  should  be  examined  for  it. 

According  to  Pfaundler  and  Schlossman,  there  is  often  present  in 
the  mouths  of  infants  a  coccus  closely  resembling  the  gonococcus,  and 
to  them  the  evidence  so  far  produced  is  not  conclusive  that  the  disease 
described  under  this  head  is  a  true  gonorrheal  stomatitis. 

Treatment  consists  in  cleansing  the  mouth  with  a  10  per  cent  borax 
solution  and  in  touching  the  ulcers  with  a  2  per  cent  solution  of  silver 
nitrate.  The  prognosis  seems  good,  and  the  disease  usually  disappears 
in  a  few  days. 

Diphtheria. — The  mucous  membrane  of  the  mouth  is  not  often 
affected  by  diphtheria,  though  it  may  be  secondary  to  a  severe  infection 
of  the  tonsils. 

Butlin  reports  a  case  of  primary  diphtheria  of  the  tongue.  The 
uncomplicated  diphtheritic  membrane  is  at  first  a  thin,  white  film  which 
appears  to  be  laid  upon  the  normal  mucous  membrane  and  which 
reappears  when  removed.  When  on  the  tonsils,  it  tends  to  spread  to 
the  uvula  and  pharynx.  As  the  disease  at  first  is  almost  afebrile,  it 
cannot  be  differentiated  from  Vincent's  angina.  It  causes  an  enlarge- 
ment of  the  lymph  nodes.  The  high  fever  and  thick  opaque  membrane 
often  observed  are  due  to  a  mixed  infection  with  pus  organisms. 
Diagnosis  is  to  be  made  by  finding  the  Klebs-Loffler  bacillus  by  culture 

A.  T.  Bristow  describes  a  pseudo  diphtheria  bacillus,  which  was 
frequently  found  by  him — once  on  impure  culture.  They  were  isolated 
in  23  out  of  136  cultures  examined  and  could  be  distinguished  from  the 
three  Klebs-Loffler  bacilli  only  by  animal  inoculations  and  by  the  be- 
havior of  the  bacilli  to  sugar. 

Anthrax. — Anthrax  is  due  to  the  local  infection,  with  the  anthrax 
bacillus,  and  has  occurred  in  butchers  who  have  held  a  knife  in  the 
mouth  while  butchering  an  infected  sheep.  In  the  cases  reported,  the 
mouth  has  shown  black  vesicles,  and  somewhat  resembled  a  gangre- 
nous stomatitis. 

Glanders  (Farcy,  Malleus). — This  is  an  infectious  disease  rather 
peculiar  to  the  horse,  and  caused  by  Bacillus  mallei.  It  is  sometimes 
transmitted  to  man  by  direct  contact.  The  disease  attacks  the  mucous 
membrane  of  the  nose  and  mouth,  is  characterized  by  the  formation  of 
nodules, — rarely  dift'use  indurations, — which  break  down  and  form 
ulcers.  It  may  be  either  acute  or  chronic,  and  its  manner  of  outset  may 
vary  greatly.  In  the  acute  variety  there  is  intense  pain  and  early 
suppuration  of  the  mucous  membrane  and  lymph  nodes,  accompanied 


INFECTIONS  OF  THE  MOUTH.  359 

by  high  fever.  The  diagnosis  is  made  possible  from  the  history  of 
exposure,  the'  formation  of  ulcers,  and  the  presence  of  the  specific 
bacillus.  The  acute  form  is  almost  invariably  fatal,  while  in  the 
chronic  form  the  death  rate  is  about  50  per  cent.  The  treatment  con- 
sists in  active  local  antisepsis. 

A.  T.  Bristow  cites  the  case  of  a  man  who  was  operated  upon  for 
a  sinus  leading  to  dead  bone  in  the  jaw.  After  curetting  and  remov- 
ing the  dead  bone,  the  sinus  healed.  Later  an  abscess  developed  in  the 
leg  and  one  in  the  arm,  which  when  opened  gave  pure  cultures  of 
Bacillus  mallei. 

Leprosy. — Leprosy  is  due  to  the  infection  from  Bacillus  leprae. 
It  is  very  chronic  and  usually  first  invades  the  nose.  It  is  characterized 
by  swellings  which  undergo  atrophy,  but  usually  break  down,  forming 
ulcers  which,  like  syphilis,  destroy  all  tissues.  These  form  scabs  and 
also  give  ofT  a  secretion  that  emits  a  peculiar,  sweet,  unpleasant  odor. 
Scars  follow,  which  contract  and  cause  distortions.  In  the  mouth  it 
usually  attacks  the  uvula  and  soft  palate,  forming  anesthetic  nodules 
which  tend  to  ulcerate.  Diagnosis  is  to  be  made  from  the  general 
symptoms  and  findings  of  Bacillus  leprae. 

Foot  and  Mouth  Disease. — This  usually  appears  as  an  epidemic, 
and  Siegel  and  others  have  shown  in  a  special  report  on  the  subject  the 
direct  connection  between  this  disease  in  man  and  cattle. 

The  characteristics  of  the  disease  are  fever — often  beginning  with 
a  rigor  accompanied  by  pain  in  the  back  and  epigastrium — nausea, 
and  anorexia.  There  is  a  superficial  inflammation  affecting  especially 
the  tongue — the  rest  of  the  mouth,  pharynx,  and  nose  to  a  less  extent. 

Small  vesicles  form  in  the  lips,  gums,  and  tongue — seldom  on  the 
pharynx  or  palate.  The  vesicles  are  at  first  clear,  but  later  become 
opaque.  When  the  vesicles  burst,  there  are  left  behind  dusky  super- 
ficial ulcers  or  erosions.  In  bad  cases  the  remaining  ulcers  are  covered 
by  a  white  fibrinous  exudate,  and  the  tongue  may  become  so  swollen  as 
to  protrude  from  the  mouth.  In  severe  or  fatal  cases  the  bacillus  has 
been  found  in  the  intestines  and  internal  organs. 

It  is  to  be  distinguished  from  scurvy  by  the  discovery  of  the  bacillus 
of  Siegel,  which  is  found  in  the  earlier  stages  of  the  vesicles  in  the 
tongue.  There  is  salivation  and  pain  on  eating,  and  the  measly  or 
vesicular  eruption  may  appear  on  the  limbs.  The  most  important  point 
in  treatment  is  prevention. 

The  disease  is  transmitted  both  by  the  milk  of  infected  cows  and 
by  contact.  The  mouth  should  be  kept  clean,  and  a  1  or  2  per  cent 
solution  of  potassium  permanganate  should  be  used  as  a  mouth  wash 
very  frequently.  Haubner  advises  painting  the  separate  vesicles  with 
a  3  per  cent  solution  of  carbolic  acid,  using  a  camel's  hair  brush  from 


360  SURGERY  OF  THE  MOUTH  AND  JAWS. 

which  the  solution  does  not  drip.  The  mouth  being  the  first  point 
attacked,  the  spread  of  the  infection  may  be  somewhat  limited  by  the 
local  treatment.  The  general  care  of  the  patient  should  receive  careful 
attention,  for  the  disease  is  often  fatal. 

Scleroma. — This  is  a  disease  that  seems  to  be  produced  by  an 
infection  with  the  scleroma  bacillus  of  Frisch.  It  usually  begins  in  the 
nose,  but  can  spread  to  the  pharynx,  lip,  face,  and  forehead.  The  nose 
may  become  thickened  like  a  bulb.  It  is  characterized  by  the  formation 
of  swellings  which  at  first  do  not  indurate  and  never  suppurate.  The 
mucous  membrane  is  at  first  soft  and  red;  but  later  the  infiltration 
becomes  as  hard  as  cartilage,  and  the  mucous  membrane  is  pale,  shrinks, 
and  is  scarred.  In  the  oral  pharynx  these  scars  may  cause  considerable 
distortion.  The  soft  palate  may  be  drawn  backward,  and  the  uvula 
obliterated. 

If  the  pillars  are  affected,  the  tongue  is  drawn  upward  and  back- 
ward. When  the  cheek  is  attacked,  fibrous  ankylosis  may  result.  It 
is  to  be  differentiated  from  diffuse  gumma  by  its  lack  of  ulceration,  its 
chronicity,  and  its  final  hardness;  from  sarcoma  by  its  bilateral  distri- 
bution, its  chronicity,  and  its  atrophic  tendency.  The  finding  of  the 
scleroma  bacillus  fixes  the  diagnosis. 

The  treatment  is  symptomatic  only,  as  no  cure  has  been  found. 

Chronic  Ulcerative  Stomatitis  (Stomatocace). — This  is  an  aggres- 
sive ulceration  of  the  gums  and  neighboring  tissues  that  never  occurs 
except  in  the  presence  of  teeth.  This  is  not  the  only  affection  that 
depends  upon  the  presence  of  teeth.  Neither  the  mercurial  stomatitis 
nor  the  oral  manifestations  of  scurvy  are  present  in  the  edentulous. 
The  disease  has  often  been  epidemic  in  barracks  and  asylums,  but  is 
almost  always  a  disease  of  children.  When  it  has  appeared  in  bar- 
racks, the  officers  have  not  been  affected,  and  it  is  therefore  thought 
to  be  due  rather  to  bad  hygiene  than  to  direct  contagion.  The  lesion 
starts  with  a  cushion-like  red  swelling  on  the  gums  near  a  tooth.  As 
the  gum  swells,  it  separates  from  the  tooth  and  later  becomes  discolored 
with  a  yellow  purulent  exudate  within  the  superficial  layers  of  the 
mucous  membrane.  Beneath  this  exudate  the  tissues  become  necrotic, 
and  in  a  short  time  the  infiltrated  area  has  been  replaced  by  an  ulcera- 
tion. As  the  ulcer  extends,  the  tooth  may  become  loose  in  its  socket 
and  thrown  off.  A  yellowish-brown  or  dirty-gray  exudate  adheres  to 
the  floor  of  the  ulcer,  and  if  detached,  there  is  free  hemorrhage. 
Blood  can  often  be  detected  between  the  child's  lips.  The  neighboring 
parts  of  the  oral  or  lingual  mucous  membrane,  which  lie  in  contact  with 
the  original  ulceration,  soon  become  involved  in  the  same  process.  The 
palate  is  not  often  involved,  but  it  may  spread  to  the  tonsils  or  even  to 
the  pharynx  and  larynx      The  tongue  becomes  thick  and  coated,  and 


INFECTIONS  OF  THE  MOUTH.  361 

there  may  be  swelling  of  the  lips  and  cheek  which  is  visible  from  the 
outside.  The  lymph  nodes  are  enlarged,  and  there  is  a  penetrating 
fetid  odor  perceptible  from  a  distance. 

Especially  in  children  the  general  condition  is  severely  affected — 
pain,  fever,  and  lack  of  appetite  being  marked.  If  treated,  the  prognosis 
is  good,  but  septic  complications  are  possible.  Bruck  regards  this  as 
an  idiopathic  disease  due  to  the  inroads  of  organisms  usually  present 
in  the  mouth.  But  Pfaundler  and  Schlossmann  would  lead  one  to  con- 
clude that  Bernheim  and  Prospischill  have  demonstrated  the  disease  to 
be  due  to  Bacillus  fusiformis  and  to  a  spirochete  acting  in  conjunction, 
the  same  cause  being  assigned  to  Vincent's  angina.  Many,  however, 
are  not  ready  to  accept  this  explanation  of  the  etiology.  It  is  more 
than  probable  that  ulcerations  clinically  somewhat  similar,  but  due 
to  different  causes,  are  grouped  under  this  head.  In  two  cases  that 
have  come  under  our  observation.  Bacillus  fusiformis  and  its  associated 
spirochete  were  demonstrated;  and  one  of  them,  on  whom  methylene 
blue  was  used  locally,  promptly  recovered  under  this  treatment.  The 
treatment  consists  in  the  use  of  an  actively  antiseptic  mouth  wash,  such 
as  a  1  or  2  per  cent  solution  of  potassium  permanganate,  and  after 
cocainization,  the  daily  applications  to  the  ulcers  of  a  10  per  cent  solu- 
tion of  formalin.  Internally,  potassium  chlorate  should  be  administered 
in  the  form  of  a  solution  for  the  first  three  or  four  days,  but  not 
continued  on  account  of  the  danger  of  renal  irritation.  If  it  is  true 
that  the  disease  is  but  another  manifestation  of  Vincent's  angina,  then 
the  application  of  the  basic  analine  dye  should  make  an  effective  local 
treatment.  With  children  the  feeding  becomes  difficult  on  account  of 
the  pain.  The  local  application  of  a  2  per  cent  solution  of  cocain  has 
been  resorted  to,  but  a  minimum  amount  of  the  drug  should  be  used. 
Fresh  air  is  an  important  factor,  and  children  should  be  kept  in  the 
open  air,  the  beds  being  moved  outdoors  or  next  to  an  open  window. 

Vincent's  Angina  (Angina  of  Plaut). — This  is  a  form  of  oral 
infection  and  tonsillitis,  which  of  late  has  attracted  considerable  atten- 
tion. It  is  apparently  caused  by  the  combined  effect  of  a  spindle- 
shaped  bacillus,  described  by  Plant  and  Vincent,  and  a  spirochete.  Ac- 
cording to  Pfaundler  and  Schlossmann,  the  disease  was  first  described 
by  the  Russians,  Szimanowsky  and  Filatov.  Often  the  bacillus  and 
the  spirochete  have  been  found  in  the  mouth  as  a  saprophyte.  Eller- 
mann  has  succeeded  in  cultivating  the  bacillus  as  a  -strict  anaerobe.  It 
is  probable  that,  like  many  other  organisms,  it  only  becomes  pathogenic 
under  certain  favorable  circumstances.  Vincent  states  that  the  dis- 
ease does  not  appear  after  the  thirty-fifth  year,  but  exceptions  to 
this  have  been  reported. 

W.  Eichmeyer  states  that  Bacillus  fusiformis  and  the  spirochete  are 


362  SURGERY  OF  THE  MOUTH  AND  JAWS. 

always  present,  but  at  times  other  organisms  predominate.  He  states 
also  that  the  disease  belongs  to  the  same  group  as  ulcerative  stomatitis, 
as  shown  by  a  similarity  of  clinical  and  anatomical  findings ;  that  Vin- 
cent's angina  may  begin  as  an  exudative  stomatitis  and  may  continue  as 
a  typical  ulcerative  stomatitis,  and  may  extend  to  the  fauces.  He  con- 
cludes that  not  only  are  Vincent's  angina  and  ulcerative  stomatitis  iden- 
tical in  their  etiology,  but  that  noma  is  due  to  the  same  organisms. 
Bacillus  fusiformis  is  found  with  the  spirochete  in  a  number  of  other 
conditions.  It  is  present  in  one  quarter  of  the  cases  of  diphtheria,  and 
is  less  frequently  found  in  scarlatina,  gingivitis  marginalis,  stomatitis 
varicellosa,  parulis,  and  morbus  maculosus  Werlhofii.  He  states,  how- 
ever, that  the  spirochete  and  Bacillus  fusiformis  are  not  found  before 
the  teeth  are  present. 

The  affection  is  characterized  by  the  formation  of  ulcers  covered 
by  a  pseudomembrane,  formed  by  a  necrosis  of  the  superficial  layers  of 
the  mucous  membrane.  This  typical  appearance  is  not  always  present ; 
when  ulceration  is  present,  it  may  be  superficial  or  deep.  In  some  cases 
the  lesion  involves  the  tonsil,  commonly  only  the  upper  part  and  on 
the  inside,  spreading  to  the  soft  palate  and  possibly  to  the  pharynx 
and  larynx.  In  others  it  will  be  found  farther  forward,  usually  near 
carious  teeth.  We  have  seen  it  the  cause  of  a  gingivitis,  involving  the 
whole  of  both  gums,  the  latter  probably  being  identical  with  the 
stomatocace.  The  patches  are  of  a  grayish-white  color,  surrounded 
by  a  red  zone,  but  separated  from  each  other  by  healthy  tissue.  Re- 
moval of  the  membrane  shows  an  ulcer  of  varying  depth,  which  bleeds 
freely  and  is  soon  covered  by  a  new  membrane.  The  ulcers  show  a 
crater-shaped  edge  and  have  a  tendency  to  involve  the  deeper  tissues 
more  than  the  surface.  The  infection  is  often  limited  to  one  side. 
There  is  swelling  of  the  lymph  nodes,  salivation,  fetor,  and  often 
some  fever.     In  advanced  cases,  the  teeth  loosen  and  drop  out. 

Trench  Mouth. — Under  this  name,  Vincent's  angina  is  one  of 
the  commonest  affections  among  the  troops  in  France,  Campbell  and 
Dyas^  reporting  that  129  cases  passed  through  their  hands  in  four 
months. 

The  prognosis  is  usually  good.  It  rarely  causes  marked  constitu- 
tional symptoms,  but  most  observers  have  found  it  to  be  remarkably 
stubborn,  often  requiring  weeks  for  its  cure. 

The  treatment  consists  in  removing  or  filling  carious  teeth  or  keep- 
ing the  mouth  clean  with  an  akaline  antiseptic  solution  or  a  1  per  cent 
solution  of  permanganate  of  potassium.  The  local  application  of  one 
of  the  basic  aniline  dyes — methylene  blue  or  violet — applied  dry  in  a 
cotton  swab  daily,  will  effect  a  cure  in  a  few  days.     Chaufford  seems 


2Campbell  and  Dyas  •      Journal  A.  M.  A.,  June  2,  1916. 


INFECTIONS  OF  THE  MOUTH.  363 

to  have  first  proposed  the  use  of  methylene  blue  for  this  purpose.  A 
10  per  cent  solution  of  formalin  will  do  the  same  thing,  but  is  very 
painful.  Of  late,  local  applications  of  arsenic  have  been  extensively 
used  with  success,  especially  in  the  form  of  a  10  per  cent  emulsion 
of  salvarsan  in  glycerine.  The  expense  of  these  drugs,  however,  is 
prohibitive.  Campbell  and  Dyas  routinely  apply  liquor  potassii  arsen- 
itis  3  or  4  times  a  day,  after  first  swabbing  the  ulcers  with  10  per 
cent  silver  nitrate  solution.  The  patient  is  also  given  large  doses  of 
Fowler's  solution  internally.  By  this  method  the  great  majority  of 
patients  are  cured  in  four  to  seven  days,  with  but  few  recurrences. 

Desquamation. — This  follows  all  forms  of  stomatitis,  but  may  be 
caused  by  the  use  of  chemical  irritants.  It  may  result  from  an  irri- 
tating mouth  wash.  Occasionally  a  neurotic,  usually  a  woman,  will 
for  some  purpose  burn  the  mouth  repeatedly  with  an  escharotic,  pro- 
ducing a  localized  desquamation.  It  is  much  more  common  to  find 
such  self-inflicted  burns  on  the  surface  of  the  skin  of  some  other  part 
of  the  body.  Though,  from  location,  its  repeated  appearance,  its  irreg- 
ular outline,  and  its  lack  of  resemblance  to  any  familiar  clinical  picture, 
the  attendant  may  suspect  the  true  nature  of  the  trouble,  it  is  difficult 
to  prove,  and  is  usually  unwise  to  make  a  direct  accusation. 

Tuberculosis. — This  occurs  in  several  forms,  but  in  all  instances 
is  caused  by  an  infection  with  the  tubercle  bacillus.  When  the  infec- 
tion occurs,  the  tissues  immediately  surrounding  the  focus  form  a  mass 
of  granulations  known  as  a  tubercle.  The  histological  structure  of  a 
tubercle  is  usually,  though  not  always,  strongly  suggestive  of  the  cause. 
In  mouth  tuberculosis  the  giant  cell  is  not  common,  and  therefore  mi- 
croscopical examination  of  the  tissue  is  not  always  helpful.  Later,  this 
tubercle,  which  in  its  center  is  poorly  supplied  with  blood,  usually  case- 
ates  or  ulcerates.  There  are  two  varieties  of  tuberculosis  of  the  soft 
tissues  of  the  mouth  which  give  a  different  appearance  and  clinically 
run  very  different  courses.  They  are  lupus  and  the  ordinary  tuberculous 
inflammation.  Lupus  is  characterized  by  the  formation  of  groups  of 
superficial  tubercles  and  a  tendency  to  scarring  and  contracting,  and 
little  aptitude  for  very  active  ulceration.  Lupus  of  the  face  is  usually 
present  with  lupus  in  the  mouth.  In  ordinary  tuberculosis  of  the 
mouth  ulceration  is,  after  the  first  stages,  often  the  most  prominent 
characteristic.  At  first  there  are  always  one  or  more  tubercles,  but 
these  may  ulcerate  so  rapidly  as  to  escape  notice.  (For  charac- 
teristics of  the  tubercles  and  the  ulceration  see  Tuberculosis  of  the 
Tongue,  Chap.  XXXVI.)  The  ulceration  may  be  so  rapid  that  it  is 
difficult  to  detect  the  outlying  area  of  tubercles.  The  infection  may  oc- 
cur in  any  part  of  the  mouth,  but  it  is  peculiar  that  tuberculosis  of  the 
maxilla  and  roof  of  the  mouth  is  not  nearly  so  virulent  as,  and  runs  a 


364  SURGERY  OF  THE  MOUTH  AND  JAWS. 

much  milder  course  than,  tuberculosis  of  the  tongue,  floor  of  the  mouth, 

or  mandible.  While  early  in  their  course  these  tuberculous  lesions 
cause  little  inconvenience  and  are  free  from  pain,  in  their  later  stages 
they  are  both  extremely  painful  and  tender,  and  cause  salivation  and 
fetor. 

A  provisional  diagnosis  of  tuberculous  lesions  is  to  be  made  partly 
from  their  clinical  characteristics  and  partly  from  serum  reactions.  An 
absolute  diagnosis  is  obtained  from  the  demonstration  of  the  tubercle 
bacilli.  Every  patient  suspected  of  tuberculosis  of  the  mouth  should  be 
given  a  thorough  physical  examination.  It  is  to  be  remembered  that 
tuberculosis  can  arise  in  a  syphilitic ;  a  gumma,  carcinoma,  or  any  other 
lesion  in  a  phthisic.  It  has  been  observed  that  gummata  show  a  greater 
predilection  for  the  dorsum  of  the  tongue,  while  the  tubercles  are  more 
apt  to  occur  in  the  tip  or  edges ;  but  this  is  only  relative,  and  does  not 
warrant  conclusions  in  the  individual  case.  The  same  is  true  of  the 
fact  that  the  tuberculous  lesions  early,  carcinomata  late,  and  gummata 
very  rarely  cause  enlargement  of  the  lymph  nodes.  The  exceptions  to 
these  rules  preclude  them  from  being  relied  upon  for  final  decision. 

The  von  Pirquet  and  other  reactions  of  the  same  character  can  be 
used  only  as  contributory  evidence;  for  after  two  years  they  are  fre- 
quently present  when  there  is  no  evidence  of  an  active  tuberculous 
lesion,  and  are  sometimes  absent  during  certain  stages  of  an  active 
tuberculosis.  Koch's  serum  reaction  is,  we  believe,  more  reliable.  If 
one  will  adopt  the  rule  of  excising  all  isolated  subacute  or  chronic 
lesions  of  unknown  cause,  then  the  preoperative  diagnosis  of  tuber- 
culous lesions  of  the  mouth  is  not  so  important.  If  one  hesitates  to  do 
this,  then  the  scrapings  of  the  tissue  should  be  examined  for  tubercles, 
and  if  this  is  negative,  an  emulsion  is  to  be  injected  into  guinea  pigs. 

The  local  treatment  of  a  tuberculous  infection  of  the  mouth  will  vary 
with  the  character  of  the  lesion,  its  location,  and  the  general  condition 
of  the  patient.  Lupus  anywhere  is  to  be  treated  with  such  milder 
measures  as  the  Finsen  light,  curetting,  the  application  of  lactic  acid, 
or  the  x-ray.  Tuberculous  nodules  and  small  ulcers  are  to  be  excised, 
and  the  defect  closed  by  immediate  suture.  In  the  roof  of  the  mouth 
and  upper  jaw,  larger  ulcers  may  be  scraped,  and  the  surface  repeatedly 
painted  with  lactic  acid.  On  the  tongue,  or  the  floor  of  the  mouth  or 
lower  jaw,  the  ordinary  tuberculous  infection  is  in  the  majority  of  cases 
as  fatal  as  cancer,  and  it  should  be  treated  accordingly.  A  possible 
exception  to  this  may  be  made  in  patients  with  pulmonary  or  general 
tuberculosis,  and  such  patients  can  be  made  much  more  comfortable. 
The  general  treatment  should  be  the  same  as  in  any  tuberculous  infec- 
tion, and  one  of  the  first  things  gained  by  excision  is  freedom  from 
pain,  rest,  and  ability  to  take   food.     Specific  vaccines  may  be  em- 


INFECTIONS  OF  THE  MOUTH.  365 

ployed  by  those  familiar  with  the  methods.  As  in  cancer,  the  favorite 
treatment  of  -tuberculosis  at  present  is  the  use  of  the  actual  cautery. 
Hygienic  treatment  should  not  be  overlooked. 

Syphilis. — ^In  all  of  its  manifestations  syphilis  is  due  to  the  in- 
fection with  Spiroclicta  pallida,  which  is  transmitted  only  by  contact. 
The  primary  lesion,  the  hard  chancre,  is  often  situated  on  the  lip, 
seldom  on  the  cheeks  or  tongue,  but  sometimes  on  the  tonsil.  It  first 
appears  as  a  crack  or  superficial  abrasion,  surrounded  by  some  indu- 
ration. Later  the  induration  increases,  but  is  partially  destroyed  by 
ulceration.  Within  the  mouth  a  fully  developed  chancre  is  usually 
rather  round  and  presents  either  a  grayish  granular  surface  due  to 
purulent  secretion  that  covers  it,  or  is  occupied  by  a  concave  ulceration. 
It  has  a  sharp  outline  and  a  hard  base.  It  is  painless  and  causes  early 
enlargement  of  the  lymph  nodes.  Without  constitutional  treatment  it 
heals  slowly,  usually  lasting  six  weeks.  Sometimes  the  secondary 
lesions  appear  before  it  is  healed. 

The  secondary  manifestations  of  syphilis  in  the  mouth  may  be  of 
an  erythematous  or  of  a  papular  or  ulcerative  type.  The  pharynx  is 
usually  affected  in  secondary  syphilis.  The  soft  palate  and  tonsils  are  ' 
reddened,  but  there  is  little  or  no  pain.  By  itself  diagnosis  of  the 
syphilitic  erythema  would  be  difficult,  but  it  usually  occurs  in  con- 
junction with  other  manifestations.  The  mucous  patch  is  a  rather 
common  intraoral  secondary  lesion,  but  is  not  found  here  as  constantly 
as  around  the  natal  and  genital  cleft.  Within  the  mouth  they  occur 
on  the  edge  of  the  tongue,  on  the  under  surface  near  the  tip  and  on 
the  dorsum,  on  the  uvula  and  palate  arches,  sometimes  on  the  tonsil 
or  posterior  pharyngeal  wall,  but  most  commonly  of  all  on  the  inner 
surfaces  of  the  lips,  where  one  can  often  see  the  papules  on  the  outer 
surface  passing  into  mucous  patches.  They  appear  as  large  or  small, 
round  or  irregular  plaques  of  a  grayish-white  color  covered  by  a  sticky 
secretion.  The  mucous  membrane  around  the  plaque,  unless  irritated, 
is  not  conspicuously  red.  They  may  disappear  quickly,  especially 
under  constitutional  treatment,  but  they  may  recur  or  be  remarkably 
persistent.  Years  after  the  lesions  have  healed,  round  pearly-white 
smooth  patches  may  be  present.  These  are  sometimes  called  Erb's 
scars.  Tertiary  lesions  are  due  to  a  gummatous  infiltration,  which  is 
much  inclined  to  ulcerate  with  total  destruction  of  the  infiltrated  tissue. 

Gummata  usually  do  not  appear  for  many  months  or  years  after 
infection.  They  may  occur  in  any  part  of  the  mouth,  but  are  more 
common  on  the  upper  surface  of  the  velum,  the  tonsil,  posterior  phar- 
yngeal wall,  palate,  and  tongue.  They  may  be  single  or  multiple,  the 
size  of  a  pea  or  a  hazelnut.  Gummata  are  sometimes  diflfuse,  giving  the 
tissues  a  leathery  feeling,  but  are  more  often  circumscribed,  in  which 


366  SURGERY  OF  THE  MOUTH  AND  JAWS. 

case  they  can  be  felt  as  distinct  nodules.  When  a  gumma  breaks  down, 
it  forms  an  ulcer  with  sharp  edges.  If  the  whole  gumma  disintegrates, 
the  edges  of  the  ulcer  will  be  formed  by  healthy  tissue,  but  more  often 
it  shows  induration.  If  the  gumma  is  deeply  situated,  there  will 
result  an  ulcer  with  deeply  undermined  edges,  or  it  may  communicate 
with  the  surface  by  a  small  opening.  A  serpiginous  or  scalloped  border 
is  a  very  common  characteristic  of  gummatous  ulcers.  An  ulcer  that 
heals  at  one  edge  as  it  spreads  at  another  is  usually  due  to  gumma,  but 
may  be  due  to  tubercle.  On  the  hard  palate  the  ulcer  often  extends 
through  to  the  nasal  cavity.  Gummatous  ulcers  are  sometimes  ex- 
tremely painful.  In  healing,  large  ulcers  often  cause  considerable 
distortion.  This  is  especially  true  when  the  ulcer  involves  the  opening 
between  the  naso-  and  the  oropharynx  (see  Chap.  XL). 

The  diagnosis  of  syphilis  is  to  be  made  on  the  history  of  the  case, 
and  the  appearance,  grouping,  and  sequence  of  the  symptoms.  Re- 
cently we  have  had  placed  at  our  disposal  the  Wassermann  and  the 
Noguchi  serum  reactions,  which  are  almost  certain.  Though  only  60 
per  cent  of  syphilitics  will  give  positive  reactions,  it  is  very  rare  that  a 
positive  reaction  cannot  be  obtained  in  the  presence  of  any  active 
syphilitic  lesion.  One  or  the  other,  or  both,  should  be  employed  in  every 
doubtful  case.  In  the  primary  and  secondary  lesions  a  diagnosis  can 
be  made  or  excluded  by  finding  or  not  finding  the  spirochete  when 
a  proper  technique  is  used.  In  the  tertiary  lesions  the  spirochete  is  not 
evident. 

Chancre  may  be  mistaken  for  carcinoma,  or  the  reverse.  Chancre 
has  a  history  of  an  acute  onset  and  is  short-lived,  especially  under 
antisyphilitic  treatment.  Aphthae  and  other  acute  mouth  lesions  may  be 
mistaken  for  mucous  patches  or  secondary  ulcers,  but  the  former  are 
always  more  acute  in  their  course.  Whenever  there  is  the  possible 
suspicion  that  we  have  to  deal  with  a  primary  or  secondary  syphilitic 
sore,  scrapings  from  the  surface  should  be  examined  for  Spirocheta 
pallida,  and  the  patient  should  be  subjected  to  a  rigid  general  exam- 
ination. Gummata  are  to  be  differentiated  from  phlegmonous  infil- 
trations by  their  subacute  course ;  from  new  growths,  especially  carci- 
nomata,  by  the  general  history  and  examination  of  the  case,  the  fact 
that  they  are  often  multiple,  and  when  there  is  the  least  doubt,  by  the 
Wassermann  reaction.  From  actinomycosis  they  are  to  be  differen- 
tiated :  by  the  manner  in  which  they  break  down — the  former  ulcerates 
and  the  latter  forms  sinuses ;  by  the  history ;  and  by  the  finding  of  the 
fungus  in  the  actinomycotic  discharge.  Both  yield  to  the  internal  ad- 
ministration of  the  iodids.  Both  the  primary  and  the  secondary  lesions 
can  transmit  the  disease ;  the  patients  should  be  warned  to  care  for 
themselves  and  others  accordingly.     Tertiary  lesions,  though  they  con- 


INFECTIONS  OF  THE  MOUTH.  367 

tain  a  few  spirochetes,  do  not  seem  capable  of  communicating  the  con- 
tagion. ' 

The  treatment  of  syphilis  is  essentially  medicinal  and  should  be 
carried  on  by  a  competent  internest  or  specialist.  When  a  chancre 
appears,  general  infection  has  already  occurred,  but  it  can  be  limited 
by  immediate  excision  of  the  primary  sore  and  institution  of  treatment 
with  either  mercury  or  salvarsan.  Secondary  sores  are  to  be  treated 
by  mercury  or  salvarsan,  the  use  of  a  cleansing  mouth  wash,  and  the 
withdrawal  of  local  irritations.  Persistent  mucous  patches  which  do 
not  yield  to  constitutional  treatment  will,  according  to  Butlin,  always 
disappear  with  the  repeated  applications  of  a  2  per  cent  solution  of 
chromic  acid.  The  treatment  of  tertiary  lesions,  gummata,  is  with 
increasing  doses  of  iodids  with  mercury,  and  the  administration  of 
salvarsan. 

PARASITES  OF  THE  MOUTH. 

Both  animal  and  vegetable  parasites  give  rise  to  disease  within  the 
mouth.  The  latter,  which  cause  the  mycoses,  are  the  most  common. 
To  this  class  probably  belongs  the  tubercle  bacillus.  Occasionally  animal 
parasites,  such  as  Cysticerciis  ccUnlosae,  Bchinococciis  (Hydatids),  Tri- 
china, and  Pilaria  inedinensis  (Guinea-worm),  are  found.  Spirocheta 
niicrodeiifium,  Spirocheta  niacrodeiitiuni,  and  Spirocheta  refringens 
may  be  constant  inhabitants  of  the  mouth. 

Thrush. — This  disease  was  recognized  and  described  by  the 
Hippocratic  writers  under  the  general  term  of  aphthae,  from  which, 
even  at  the  present  day,  many  do  not  make  a  distinction — among  the 
latter  is  no  less  an  observer  than  Butlin.  It  is  caused  by  growths  of 
the  fungus,  Oidinni  albicans,  which  is  most  commonly  found  in  the 
mouths  of  unhealthy,  unclean  infants,  but  is  also  found  in  debilitated 
and  old  persons.  The  favorite  sites  of  onset  are  the  anterior  part  of  the 
tongue,  the  gums,  and  the  cheeks.  It  thrives  best  in  infants  who  receive 
starchy  foods.  It  is  very  contagious  and  spreads  easily  by  the  use  of 
unclean  nipples,  pacifiers,  etc.  It  often  occurs  in  the  mouths  of  in- 
fants with  cleft  palate.  The  disease  first  begins  by  the  appearance  of 
pinhead  white  spots  that  spread  and  unite,  forming  patches.  The 
patches  cannot  be  easily  removed,  for  the  fungus  grows  not  only  on 
the  surface,  but  into  the  epithelium  and  the  underlying  connective  tissue. 
When  torn  off,  it  leaves  the  underlying  mucous  membrane  red,  softened, 
and  bleeding  easily.  The  mucous  membrane  between  the  patches  shows 
a  simple  stomatitis,  which  usually  precedes  the  specific  infection.  After 
persisting  some  time,  the  color  of  the  growth  becomes  yellow  or  brown- 
ish and  scales  off  easily.  The  onset  of  the  disease  is  painless  and, 
therefore,  is  overlooked. 


368  SUlRGERY  OF  THE  MOUTH  AND  JAWS. 

If  it  has  not  preceded  the  infection,  gastrointestinal  disturbances 
are  hkely  to  follow,  high  fever  may  be  present,  and  soreness  may  inter- 
fere with  sucking.  The  growth  is  usually  restricted  to  the  mouth,  but 
it  may  continually  spread  to  the  nose,  larynx,  pharynx,  esophagus,  and 
stomach.  It  usually  responds  quickly  to  treatment,  but  sometimes 
recurs  rapidly.  In  debilitated  infants  or  adults  the  recurrence  is  a  sign 
of  the  lack  of  general  resistance  and  is  a  bad  symptom.  Occasionally  the 
fungus  is  carried  into  the  blood,  producing  a  general  infection,  which 
is  the  most  serious  form  of  the  disease.  In  its  passage  into  the  tissues, 
the  fungus  may  be  accompanied  by  pus  organisms,  giving  rise  to  a  mixed 
infection.  The  fungus,  accompanied  by  pus  organisms,  may  follow  the 
Eustachian  canal  into  the  middle  ear,  causing  a  suppurative  otitis 
media.  Injudicious  efforts  at  cleansing  the  mouth  may  give  rise  to 
Bednar's  ulcers. 

The  diagnosis  of  thrush  rests  upon  the  appearance  and  growth  of 
the  patches,  and  the  fact  that  they  are  in  the  early  stage  removed  with 
difficulty  and  at  once  recur.  From  aphthae  they  are  clinically  distin- 
guished by  their  color,  which  is  at  first  dead  white,  and  by  the  fact  that 
the  growth  of  thrush  has  an  uneven  surface  and  is  elevated  above  the 
surface  of  the  epithelium.  The  diagnosis  can  be  made  absolutely 
certain  by  a  microscopical  examination  of  the  membrane,  which  shows 
the  specific  fungus.  The  picture  shown  is  a  network  of  doul^le  threads 
with  interrupting  constrictions  that  form  chains  of  many  Hnks,  Inter- 
posed among  the  threads  are  seen  clusters  of  round  or  oval  highly 
refracting  spores. 

Treatment  consists  partly  in  general  care  of  the  patient,  fresh  air, 
clean  utensils,  and  the  avoidance  of  starchy  foods.  Although  thrush 
thrives  in  an  acid  medium  and  renders  the  mouth  acid,  many  clinicians 
claim  that  boric  acid  holds  first  place  as  a  local  application.  In  infants 
this  is  safely  applied  by  means  of  the  boric  acid  teat  of  Esmarch,  which 
consists  of  a  compressed  pad  of  absorbent  cotton,  impregnated  with 
powdered  boric  acid.  The  pad,  which  should  be  about  1^^  to  3  centi- 
meters in  diameter,  is  covered  with  cotton  cloth  and  then  dipped  into 
a  .01  per  cent  solution  of  saccharin.  As  the  infant  champs  and  sucks 
the  teat,  the  mouth  is  mechanically  cleansed,  and  the  boric  acid  is  well 
distributed.  A  more  common  remedy  among  the  laity  is  the  use  of 
borax,  either  in  the  somewhat  irrational  form  of  borax  and  honey  or 
in  solution.  We  prefer  a  solution  of  5  per  cent  borax  and  15  per  cent 
glycerin  in  water,  and  have  seen  this  clean  off  a  case  in  a  few  hours 
when  the  boric  acid  treatment  had  completely  failed.  We  believe  it 
wise  to  make  up  the  teat  with  equal  parts  of  borax  or  sodium  bi- 
carbonate. If  infants  will  not  use  the  teat,  Pfaundler  and  Schlossmann 
recommend  that  they  be  allowed  to  suck  on  a  brush  dipped  in  a  2  per 


INFECTIONS  OF  THE  MOUTH.  369 

cent  solution  of  silver  nitrate.  Infants  fed  on  condensed  milk  some- 
times present  white  spots  on  the  tongue  that  somewhat  resemble  thrush. 
When  removed,  they  appear  after  the  next  feeding. 

Actinomycosis. — This, is  due  to  an  infection  with  the  ray  fun- 
gus, the  same  that  causes  "lumpy  jaw"  in  cattle.  The  fungus  is  nor- 
mally found  in  grain  and  probably  most  frequently  finds  its  way  into 
the  mouth  from  the  habit  of  chewing  on  straws.  From  the  mouth  it 
most  commonly  enters  the  tissues  through  decayed  teeth.  The  disease 
first  manifests  itself  in  the  form  of  a  small  nodule,  which  for  a  time 
may  give  no  trouble,  but  later  softens  and  forms  sinuses  from  which 
is  discharged  a  thin  fiuid  which  usually  contains  the  fungus.  It  may 
be  extremely  painful.  The  process  is  rather  indolent  and  tends  to  form 
hard  swellings  situated  most  commonly  near  the  angle  of  the  jaw. 
It  does  not  commonly  involve  bone,  but  may  do  so  (see  p.  388). 

Diagnosis  is  made  from  the  chronic  induration  and  sinuses,  and  from 
the  finding  of  the  fungus  in  the  discharge.  This  is  sometimes  seen 
macroscopically  as  small  round  "sulphur  granules,"  or  it  may  require 
a  microscopical  examination.  When  the  fungus  cannot  be  found  in 
cover-glass  preparations,  it  can  sometimes  be  demonstrated  in  glycerin 
agar  cultures.  The  treatment  consists  in  curetting  away  the  granuloma 
and  in  the  internal  administration  of  potassium  iodid  in  large  doses, 
or  copper  sulphate  to  the  limit  of  toleration.  Potassium  iodid  is  the 
older  treatment,  but  Bevan,  based  on  observations  made  at  the  Wisconsin 
Experimental  Agricultural  Station,  proposed  the  copper  sulphate  treat- 
ment in  man  and  reports  a  number  of  successes.  Formerly  the  granu- 
loma of  actinomycosis  was  confounded  with  sarcoma. 

The  sulphate  of  copper  treatment  has  not  lived  up  to  its  promise. 
The  iodids  are  still  the  sheet  anchor  of  the  medical  treatment;  with 
the  addition  of  the  x-ray,  as  suggested  by  O'sler,  the  writer  believes 
this  form  the  best  way  to  handle  these  cases.  Iodid  is  given  to  the 
limit  of  the  patient's  tolerance,  then  repeated  applications  of  the  x-ray, 
continuing  the  iodid  and  x-ray  treatment  until  the  induration  is  entirely 
absorbed.  Very  small  doses  of  the  x-ray  should  be  given  at  first 
until  the  patient's  tolerance  is  established.  We  have  seen  very  severe 
poisoning  result  from  excessive  use  of  x-ray  in  actinomycosis.  This 
treatment  should  be  thoroughly  tried  out  before  the  patient  is  subjected 
to  an  operation,  and  the  latter  will  probably  not  be  necessary. 

Leptothrix. — This,  a  constant  inhabitant  of  the  mucus  of  the 
pharynx,  may  grow  in  masses  on  the  base  of  the  tongue  or  faucial 
tonsils,  or  in  the  cavities  in  teeth.  It  forms  white  or  yellowish  points, 
which  are  not  easily  removed.  The  growth  is  stubborn  and,  though 
it  causes  few  symptoms,  is  difficult  to  overcome. 


370  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Sarcina.— This  may  grow  on  the  mucous  membrane  in  white 
patches,  which  in  appearance  resemble  thrush,  and  the  treatment  is  the 


same 


(For  the  diseases  that  most  commonly  manifest  themselves  on  the 
tongue,  see  Chapter  XXXVI.) 


CHAPTER  XXVI. 

INFECTIONS  OF  THE  TEETH,  PERIDENTAL  TISSUES, 
AND   MAXILLARY  BONES. 

Chronic  oral  infections  are  now  recognized  as  the  cause  of  many 
serious  disabilities.  About  75  per  cent  of  adults  have  been  shown 
to  have  infections  about  the  teeth  which  have  destroyed  enough  of 
the  bone  to  be  easily  demonstrable  by  roentgenographic  examination^. 
Miller-  called  attention  to  the  relationship  of  mouth  infections  to 
systemic  disease  in  1891 ;  Hunter^  declared  in  1911  that  oral  sepsis 
was  a  most  prolific  cause  of  serious  secondary  effects;  studies  by 
Billings*  and  Rosenow''  of  focal  infections  in  general  and  by  Gilmer'' 
and  others  of  the  oral  infections  in  particular,  demonstrated  what 
Hunter  had  observed  clinically.  It  is  therefore  important  that  careful 
inquiry  be  made  of  the  causes  which  lead  to  the  establishment  of 
these  mouth  foci  and  the  means  by  which  they  may  be  prevented  or 
eliminated.  This  requires  an  understanding  of  the  peculiarities  of 
the  tissues   involved,  especially  the  peridental   membrane. 

The  bones  of  the  jaw  differ  in  no  essential  from  bones  composing- 
other  parts  of  the  skeleton,  and  they  are  subject  to  the  same  diseases ; 
but  from  environment,  and  possibly  from  other  causes,  are  more 
prone  to  some,  and  less  so  to  other,  pathologic  processes. 

The  body  of  the  lower  jaw  has  an  outer  thick  wall  composed  of 
hard,  compact  bone,  and  contains  cancellous  bone  and  a  large  open 
canal  which  carries  the  nutrient  artery  and  inferior  dental  nerve. 
During  the  period  of  growth,  the  neck  is  separated  from  the  condyle 
by  an  epiphysical  cartilage,  so  that  the  mandible  is  a  true  long  bone 

lArthur  D.  Black  :  Roentgenographic  and  Microscopic  Studies  of  Tissues  Involved 
in  Chronic  Mouth  Infections,  Journal  A.  M.  A.,  1917,  Ixlx,  599. 

2W.  D.  Miller  :  The  Human  Mouth  as  a  Focus  of  Infection,  Dental  Cosmos,  1891, 
xxxiil,    689. 

swilllam  Hunter:  Role  of  Sepsis  and  Antisepsis  in  Medicine,  Lancet,  London,  Jan. 
14,  1911. 

4Frank  Billings  :  The  Medical  Management  of  Chronic  Arthritis,  Illinois  Medical 
Journal,  Sept.,  1914  ;  Chronic  Focal  Infections  and  Their  Etiologic  Relations  to  Arthritis 
and  Nephritis,  Archives  of  Internal  Medicine,  1912,  ix,  484  ;  also,  Illinois  Medical  Jour- 
nal, 1912,  xxi,  261  ;  Chronic  Focal  Infections  as  a  Causative  Factor  in  Chronic  Arthritis, 
Journal  A.  M.  A.,  1913,  ixi,  819  ;  Clinical  Aspect  and  Medical  Management  of  Arthritis 
Deformans,  Illinois  Medical  Journal,  1914,  xxv,  11  ;  Bacteriology  of  Cholecytitis  and  Its 
Production  by  Injection  of  Streptococci,  Journal  A.  M.  A.,  1914,  Ixiii,  2024. 

5E.  C.  Rosenow :  Transmutations  w^lthin  the  Streptococcus-Pneumococcus  Group, 
The  Journal  of  Infectious  Diseases,  January,  1914,  xiv,  1  ;  The  Etiology  of  Acute  Rheu- 
matism, Articular  and  Muscular,  The  Journal  of  Infectious  Diseases,  January,  1914,  xiv, 
61  ;  Lesions  Produced  by  Various  Streptococci ;  Endocarditis  and  Rheumatism,  New  York 
Medical  Journal,  Feb.  7,  1914  ;  Etiology  or  Arthritis  Deformans,  Journal  A.  M.  A.,  April 
11,  1914,  1146  ;  The  New  Bacteriology  of  Various  Infections  as  Determined  by  Special 
Methods,  Journal  A.  M.  A.,  Sept.  12,  1914,  903  ;  Bacteriology  of  Cholecystitis  and  Its 
Production  by  Injection  of  Streptococci,  Journal  A.  M.  A.,  Nov.  21,  1914,  1835. 

^Thomas  L.  Gilmer:  Chronic  Oral  Infections,  Illinois  Medical  Journal,  1912,  xxi, 
275. 

371 


372  SURGERY  OF  THE  MOUTH  AND  JAWS. 

with  a  diaphysis  and  two  epiphyses.  The  bodies  of  the  maxillae 
are  of  less  compact  bone,  and  the  dental  nerves  occupy  several  small 
canals.  The  alveolar  processes  are  composed  of  bone  which  is  almost 
cancellous,  except  that  the  thick  outer  plates  of  dense  -bone  of  the 
mandible  cover  these  processes  also.  Many  minute  foramen  pene- 
trate the  outer  plate  of  the  alveolar  process  of  the  upper  jaw,  but 
there  are  very  few  in  the  lower,  being  confined  almost  entirely  to 
the  crests  of  the  septi  between  the  teeth.  This  difference  in  structure 
makes  for  much  more  satisfactory  results  in  the  use  of  novocain  for 
the  extraction  of  teeth  and  operations  involving  the  bone  of  the 
upper  jaw  as  compared  with  the  lower,  it  being  more  often  necessary 
to  block  the  lower  at  the  mandibular  foramen.  The  jaw  bones  are 
covered  with  periosteum,  which  dips  into  the  tooth  sockets  lining 
each  completely  and  furnishing  an  attachment  for  the  fibers  of  the 
peridental  membrane,  which  connect  the  alveolar  periosteum  with  the 
cemental  covering  of  the  roots  of  the  teeth. 

The  Cementum  is  a  specialized  tissue,  closely  analagous  to  super- 
iosteal  bone,  but  different  in  that  it  has  no  circulation  of  blood.  The 
cementum  is  of  itself  an  entirely  passive  tissue,  and  when  stripped 
of  the  overlying  soft  tissue,  it  dies  just  as  superiosteal  bone  dies 
when  pus  lifts  the  periosteum  away  from  it.  Since  there  is  no 
circulation  of  blood  in  the  cementum,  the  dead  portion  cannot  be 
exfoliated,  as  is  a  piece  of  necrosed  bone.  Practically  all  cases  of 
chronic  mouth  infections  are  due  either  to  alveolar  abscesses  at  the 
apices  of  roots  or  to  pus  pockets  along  the  sides  of  the  roots,  and 
in  both  the  necrosed  cementum  is  the  tissue  responsible  for  the  main- 
tenance of  the  chronicity.  When  the  peridental  membrane  has  been 
detached  from  the  cementum  by  suppuration,  it  does  not  become 
reattached,  partly  because  the  specialized  elements  of  the  peridental 
membrane — the  cementoblasts  and  the  principal  fibers  that  extend 
from  alveolar  process  to  the  tooth  root,  and  which  are  necessary  to  a 
normal  reattachment — have  been  destroyed,  and  partly  because  of  the 
changed  nature  of  the  cementum  itself.  The  absorption  by  the 
cementum  of  the  products  of  the  suppurative  process  renders  it  non- 
chemotactic. 

The  condition  of  the  cementum  in  such  cases  may  be  illustrated 
by  the  physiological  action  of  the  surrounding  tissues  in  cases  of  im- 
planted or  replanted  teeth.  If  a  tooth,  which  has  been  dislodged  by 
accident,  is  immersed  in  physiologic  salt  solution  for  a  time  and  then 
replaced  in  the  socket  (the  pulp  tissue  having  been  removed  from 
the  root  canal,  and  the  canal  having  been  filled  with  gutta-percha) 
it  will  as  a  rule  become  firmly  held  by  the  surrounding  tissue  within 


INFECTIONS  OF  THE  TEETH.  373 

a  few  weeks.'^  If,  however,  such  a  tooth  should  be  immersed  in  one 
of  the  essential  oils  or  almost  any  antiseptic  solution,  there  will  be 
no  attachment  of  the  surrounding  tissues,  and  the  tooth  will  not  be 
retained.  The  cementum  is  similarly  non-chemotactic  if  it  has  ab- 
sorbed the  products  of  suppuration;  therefore  reattachments  of  tissue 
may  not  be  expected  over  areas  made  bare  by  chronic  suppuration. 

The  Peridental  Membrane  is  the  tissue  which  fills  the  space 
between  the  tooth  root  and  the  surrounding  bone  of  the  alveolar 
process ;  and  also  covers  the  root  beyond  the  crest  of  the  alveolar 
process  as  far  as  the  junction  of  the  root  and  crown  of  the  tooth. 
This  membrane  is  made  up  of  principal  fibers,  ordinary  connective 
tissues,  cementoblasts,  osteoblasts,  blood  vessels  and  nerves.  The 
principal  fibers  either  connect  the  cementum  with  the  bone  of  the 
alveolar  process,  or  pass  directly  across  over  the  crest  of  the  alveolar 
septi  from  tooth  to  tooth,  or  pass  outward  from  the  cementum  into 
the  soft  tissue  about  the  neck  of  the  tooth.  These  fibers  serve  to 
cushion  the  tooth  against  the  stress  of  mastication  and  to  support  the 
gingivae,  causing  the  latter  to  hug  tightly  about  the  teeth.  The  root 
ends  of  these  fibers  are  imbedded  in  the  cementum,  and  the  cement- 
oblasts lie  on  the  surface  of  the  cementum  between  the  fibers ;  in  the 
same  manner  the  other  ends  of  the  fibers  which  pass  to  the  bone 
are  imbedded  in  it,  the  osteoblasts  occupying  the  space  between  them. 
The  peridental  membrane  is  peculiarly  well  supplied  with  blood,  some 
vessels  entering  this  tissue  at  the  root  apex,  others  over  the  crest 
of  the  alveolus,  and  still  others  passing  directly  through  the  surround- 
ing bone. 

The  Mucous  Membrane  lining  the  mouth  is  closely  adherent  to 
all  bony  parts.  That  covering  the  alveolar  processes  is  termed  the 
gums,  and  the  portions  of  the  gums  immediately  surrounding  the 
teeth  are  called  the  gingivae.  The  epithelium  of  the  gingivae  is 
thicker  and  the  cells  are  more  closely  packed  than  elsewhere  in  the 
mouth.  Many  long  legs  of  connective  tissue,  with  blood  vessels,  pro- 
ject far  into  this  gingival  epithelium.  It  will  thus  be  noted  that  the 
gingivae  are  adapted  for  hard  usage  and  quick  repair,  so  that  they 
can  withstand  the  wear  and  tear  of  mastication.  The  gingivae  stand 
as  protecting  tissues  to  the  deeper  seated  peridental  membranes. 

It  is  not  necessary  to  refer  to  the  teeth  except  to  call  attention 
to  the  fact  that  the  innermost  tissue — the  pulp — is  directly  connected 
with  the  peridental  structures  via  the  foramen  in  the  ends  of  the 
roots  and  offers  a  passage  for  the  transmission  of  infection.  The 
bulk  of  the  tooth  is  composed  of  dentin,  the  root  portion  of  which 
is  covered  with  cementum,  and  the  crown  portion  with  enamel. 


''Teeth  replanted  are  lost,  as  a  rule,  within  from  three  to  five  years,  as  a  result  of 
the  absorption  of  their  roots. 


374 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


We  may  look  upon  the  mouth  as  a  machine  which  has  been 
especially  adapted  for  the  performance  of  its  function  of  mastication 
of  food,  and  subject  to  many  injuries  and  much  wear  and  tear.  The 
hard  enamel  of  the  teeth  not  only  performs  its  principal  function  of 
biting  and  crushing',  but  also  protects  the  dentin  and  pulp  from 
injury  and  irritation.  The  gingivae  must  also  withstand  much  irri- 
tation and  sufifer  many  slight  injuries,  which  they  are  exceptionally 
well  prepared  to  do  by  the  denseness  of  their  structure,  and  the  pro- 
vision for  quick  repair.     Thus  they  protect  the  peridental  membrane. 

Chronic  foci  of  infection  in  the  mouth  may  become  established  as 
a  result  of  an  initial  injury  or  break  in  either  of  these  two  protective 


Fig  326. 


Fig.  327. 


Fig.  326.  Sketch  illustrating  route  by  which  iufection  from  a  cavity  of  decay 
reaches  the  tissues  about  the  apex  of  root.  a.  enamel  of  crown  ;  h,  pulp  chamber  ;  c, 
fepical  foramen  ;  d,  cementuiu  covering  root ;  e,  peridental  membrane  connecting  root  with 
bone  :  f,  bone  ;  g,  cavity  of  decay  ;  h,  point  at  which  pulp  is  exposed  by  decay  ;  i,  abscess 
cavity  in  bone.  Arrow  marks  route  of  travel  of  infection  from  the  cavity  of  decay  via 
the  pulp  tissue  and  through  the  apical  foramen  to  the  tissues  beyond. 

Fig.  327.  Sketch  showing  route  by  which  infection  beginning  in  the  gingiva  involves 
and  destroys  the  peridental  membrane  and  alveolar  process  and  forms  a  pus  pocket  along 
the  side  of  the  root.  a,  enamel  of  crown  ;  h,  free  margin  of  gingiva ;  c,  subgingival 
space,  between  free  gingiva  and  enamel  of  crown  ;  d,  cementum  covering  root ;  e,  peri- 
dental membrane  connecting  root  with  bone  ;  f,  bone  ;  g,  gum.  Arrow  on  opposite  side 
shows  route  of  travel  of  infection  beginning  in  the  gingiva  and  gradually  destroying 
peridental  membrane  and  bone  of  alveolar  process. 


tissues.  The  enamel  may  be  penetrated  by  dental  caries,  and  if  neg- 
lected, the  case  progresses  until  the  pulp  tissue  becomes  inflamed 
and  dies ;  infection  of  the  pulp  tissue  occurs  and  may  involve  the 
tissues  about  the  root  apex,  forming  an  alveolar  abscess  (Fig.  326). 
Or  the  gingivae  may,  as  a  result  of  irritation  or  injury,  become  in- 
fected and  this  may  gradually  involve  and  destroy  the  peridental 
membrane  (Kig.  327).  The  one  route  is  through  the  tooth  to  the 
tissues  at  the  root  end,  the  other  is  along  the  outside  of  the  root.  In 
both,  the  destructive  processes  include  the  peridental  membrane,  the 
bone  of  the  alveolar  process  and  the  cementum  covering  the  root  of 
the  tooth.  Therefore  in  considering  the  physiological  processes  neces- 
sary to  the  repair  of  these  conditions,  the  problems  for  both  are  much 
the  same. 


INFECTIONS  OF  THE  TEETH. 


376 


ALVEOLAR  ABSCESS. 

An  alveolar  abscess  is  always  a  sequella  of  the  death  of  the  pulp 
of  a  tooth.  Usually  the  pulp  becomes  inflamed  and  dies  as  a  result 
of  its  exposure  by  dental  caries.  Occasionally  a  pulp  will  die  as  a 
result  of  a  blow  or  other  injury  to  the  tooth,  there  being  possibly  no 
cavity  in  the  tooth.  In  one  case  the  pulp  tissue  may  be  infected 
directly  from  the  mouth,  and  in  either  the  infection  may  be  brought 
by  the  blood  stream.  The  infection  may  pass  through  the  foramen  at 
the  end  of  the  root,  involve  the  periapical  tissues,  and  develop  an 
alveolar  abscess. 


Fig.  328. 

Fig.  328.  Sketch  illustrating  a  case  of  acute  alveolar  abscess  from  a  lower  incisor 
tooth  in  which  the  pus  has  penetrated  the  periosteum  on  the  labial  surface  of  the  bone.  a. 
cavity  of  bone  at  apex  of  root ;   c,  lower  lip  ;   d,  tooth. — G.   V.  Black. 

Fig.  329.  Sketch  illustrating  case  of  acute  alveolar  abscess  from  a  lower  incisor 
tooth  in  which  the  pus  has  lifted  the  periosteum  from  the  labial  plate  of  bone,  but  has 
not  penetrated  the  periosteum,  a,  abscess  cavity  at  apex  of  root ;  b,  pus  lying  between 
the  periosteum  and  bone  ;  c,  lower  lip  ;  d,  tooth. — G.  V.  Black. 

Alveolar  abscess,  usually  in  the  chronic  form,  also  results  in  an 
undetermined  percentage  of  cases  from  tissue  destroying  drugs  such 
as  phenol,  oil  of  cassia,  and  preparations  containing  formalin,  which 
have  been  sealed  in  the  root  canals  in  "treating"  the  teeth,  by  their 
escape  through  the  root  foramen.  Occasionally  an  abscess  is  caused 
by  a  piece  of  the  gutta-percha  (used  in  filling  the  canal  after  the 
removal  of  the  pulp)  being  pushed  through  the  end  of  the  root. 

Acute  Alveolar  Abscess  may  result  from  infection  of  the  bone 
about  the  root  apex,  accompanied  by  all  the  symptoms  of  an  acute 


376  SURGERY  OF  THE  MOUTH  AND  JAWS. 

inflammation.  The  pain  often  being  especially  severe,  because  of  the 
confinement  within  the  bone.  It  is  in  this  respect  comparable  to  an 
intramedullary  abscess  in  a  long  bone. 

The  pus  will  usually  burrow  its  way  to  the  surface  of  the  bone, 
more  often  to  the  labial  or  buccal  side,  and  penetrate  the  outer  plate, 
almost  directly  opposite  the  apex  of  the  tooth  which  is  abscessed  (Fig. 
328).  As  a  rule,  it  will  penetrate  the  periosteum  also,  when  the 
severe  pain  will  subside  and  the  face  may  become  much  swollen. 
Occasionally  the  periosteum  will  resist  and  will  be  lifted  from  the 
bone,  with  the  pus  underneath,  the  result  being  a  broad  flat  swelling 
— a  superiosteal  abscess.  In  such  cases  it  is  more  diflficult  to  detect 
the  presence  of  pus  by  palpation.  Necrosis  of  the  bone  is  likely  to 
result  (Fig.  329). 

There  are  many  variations  in  the  routes  along  which  pus  may 
burrow.  In  the  upper  jaw,  from  the  bicuspid  and  molar  teeth,  it 
may  penetrate  the  floor  of  the  maxillary  sinus ;  from  the  incisors,  the 
discharge  may  be  through  the  floor  of  the  nose.  Occasionally  it  will 
reach  the  periosteum  above  the  attachment  of  the  buccinator  muscle 
and  will  then  discharge  through  the  cheek,  or  if  above  the  nasal 
muscles  it  may  discharge  in  the  region  of  the  inner  canthus  of  the 
eye.  From  the  lower  teeth,  the  exit  of  pus  from  the  bone  on  the 
lingual  side  below  the  attachment  of  the  mylohyoid  muscle  may  result 
in  much  sw'elling  of  the  floor  of  the  mouth ;  if  the  abscess  is  from 
the  molar  teeth,  it  may  find  its  way  under  the  deep  fascia  and  follow 
the   sternocleidomastoid   to   the   clavicular   region. 

Chronic  Alveolar  Abscess  -will  practically  always  follow  the 
acute  form  unless  the  dead  pulp  is  removed  from  the  tooth  soon 
after  the  acute  symptoms  subside.  In  many  cases,  the  chronic  abscess 
presents  with  no  history  of  the  acute  form ;  in  fact,  the  chronic 
abscess  may  exist  for  many  years  without  recognizable  symptoms,  or 
it  may  flare  up  in  acute  form  at  any  time.  Some  patients  will  give  a 
history  of  many  acute  exacerbations  from  the  same  tooth  over  a  period 
of  years.  During  epidemics  of  tonsillitis  and  influenza,  these  chronic 
abscesses  are  likely  to  assume  the  acute  form. 

As  has  been  previously  mentioned,  the  essential  pathological  feature 
to  be  remembered  in  the  case  of  the  chronic  alveolar  abscess  is  the 
denuded,  pus-soaked  cementum.  If  the  tissue  about  the  apex  of  the 
root  is  once  destroyed  by  suppuration,  it  seems  quite  certain  that 
such  a  case  never  heals,  even  though  the  original  cause,  the  dead 
pulp,  may  have  been  removed  and  the  root  canal  made  aseptic  and 
properly  filled.  The  denuded  cementum  then  becomes  the  cause  of 
the  continuation  of  the  abscess. 

There  are  certain  dififerences  to  be  noted  in  considering:  the  several 


INFECTIONS  OF  THE  TEETH. 


377 


forms  of  these  chronic  abscesses.  In  a  large  percentage,  there  is  a 
sinus  discharging  through  the  gum  or  elsewhere.  The  discharge 
may  be  continuous  or  intermittent.  If  the  latter,  the  sinus  opening 
will  often  close  and  be  reopened  with  each  exacerbation.  A  chronic 
abscess  may  discharge  through  the  root  canal  of  the  tooth,  if  the 
crown  is  badly  decayed  and  the  pulp  chamber  is  exposed  to  the  mouth. 
A  common  form,  of  much  greater  frequence  than  was  supposed  before 
the  advent  of  the  x-ray,  is  the  blind  alveolar  abscess,  which  consists 
of  an  abscess  cavity  about  the  root  apex  without  a  route  of  discharge. 


Fig.   331. 
Figs.  330  and  331.    Ptiotographs  of  plaster  model  of  a  case  of  chronic  abscess  with  a 
sinus,  from  mesial  root  of  lower  first  molar.    A  sharp  steel  probe  was  passed  into  the  sinus 
and   it  was  found  that  there  was  au  extensive   destruction   of  bone   about   the   root.      The 
tooth  was  extracted. — G.    V.   Black. 

There  will   often  be  neither  sign  nor  symptom  of  such   an   abscess, 
except  as  shown  by  the  radiograph. 

In  any  form  of  chronic  alveolar  abscess,  the  tooth  may  be  tender 
to  pressure,  there  may  be  complaint  of  dull  pain,  or  of  an  occasional 
"neuralgia"  anywhere  about  the  face  on  the  affected  side.  The  tooth 
will  be  loose  if  there  has  been  considerable  destruction  of  its  attach- 
ment to  the  bone;  it  is  likely  to  be  discolored — darker  than  its  neigh- 
bors— although  it  may  not  be.  In  most  cases  a  radiograph  will  show 
very  accurately  the  extent  to  which  the  bone  has  been  destroyed,  also 
the  amount  of  the  cementum  which  has  been  denuded.     In  view   of 


378 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  high  prevalence  of  these  abscesses  in  aduUs,  the  time  is  at  hand 
when  every  thorough  examination  should  include  radiographic 
views  of  all  the  teeth  and  adjacent  bone. 

The  following  classification  of  chronic  alveolar  abscesses  is  given 
by  G.  V.  Black :« 

Chronic  Abscess  with  Sinus.  There  is  a  direct  route  for  the 
discharge  of  pus,  extending  from  a  cavity  in  the  bone  about  the  apex 
of  the  root,  through  the  alveolar  process  and  soft  tissues  to  the  surface 
of  the  gum  in  a  position  immediately  over  the  root  of  the  tooth  which 
has  caused  the  abscess  (see  Figs.  330,  331,  and  332).  Less  frequently, 
the  point  of  discharge  may  be  considerably  remote,  either  within  the 
mouth  or  upon  the  face  or  neck. 


Fig.  332. 


Pig.  333. 


Fig.  332.  Reproduction  of  radiograph  showing  a  chronic  alveolar  abscess  at  the 
apex  of  root  of  upper  lateral  incisor. — G.  V.  Black. 

Fig.  333.  Reproduction  of  radiograph  showing  two  blind  alveolar  abscesses,  one  at 
the  apex  of  each  root  of  a  lower  first  molar. — G.  V.  Black. 


Chronic  Abscess  Discharging  Through  Root  Canal.  Those 
cases  in  which  the  discharge  is  through  the  root  canal  are  not  different 
from  those  having  a  sinus,  except  that  the  root  canal  has  offered  the 
route  of  least  resistance.  These  are  liable  at  any  time  to  take  on  a 
more  acute  form  by  the  plugging  of  the  root  canal  with  food  debris. 

Blind  Abscess.  The  term  blind  alveolar  abscess  seems  appro- 
priate as  descriptive  of  the  form  having  no  route  of  discharge.  This 
term  is  widely  known  and  used  by  the  profession,  and  the  writer 
knows  of  no  English  term  which  describes  it  better.  A  very  limited 
number  of  abscesses  of  this  type  are  amenable  to  treatment.  Cysts 
are  more  likely  to  be  formed  in  this  than  in  any  other  class  of  cases. 
It  js  probable  that  a  very  large  proportion  of  these  have  more  or 
less  characteristic  elements  of  cyst  formation  (Fig.  333). 


8G.    v.    Black  :       Special    Dental    Pathology,    36.5. 


INFECTIONS  OF  THE  TEETH. 


370 


Chronic  Abscess  with  Intermittent  Discharge.  This  form  is 
practically  a  combination  of  the  other  forms.  An  abscess  with  a 
sinus  may  change  to  the  blind"  form  by  the  closing  of  the  sinus;  it 
may  then  discharge  again.     These  changes  may  occur  frequently. 


Fig.  334.  Lower  jaw  of  a  Flat-Head  Indian  from  Columbia  River,  Oregon,  showing 
destruction  of  bone  by  a  chronic  alveolar  abscess  about  the  distal  root  of  the  first  molar. 
The  bone  about  the  first  molar  of  the  opposite  side  is  in  practically  the  same  condition. 
This  is  typical  of  the  injury  which  occurs. — G.  V.  Black. 


DISEASES  OF  THE  GINGIVAE  AND   PERIDENTAL 
MEMBRANE. 

Acute  Ulcerous  Gingivitis.  This  disease  was  first  described  by 
Gilmer^  and  its  bacteriology  has  been  more  recently  worked  out  by 
him.  It  was  rarely  seen  previous  to  the  outbreak  of  the  war,  but  is 
very  common  among  the  men  in  the  trenches,  being  termed  "trench 
mouth." 

In  his  description,  Gilmer  states  that  the  onset  is  sudden,  there 
being  a  slight  malaise,  followed  by  rapid  ulceration  of  the  gingivae 
about  two  or  three  teeth,  generally  extending  later  to  the  gums.  The 
buccal  and  interproximal  gingivae  are  most  seriously  involved,  deep 
pockets  being  formed  between  the  teeth.  Within  twenty-four  hours 
the  parts  attacked  have  the  appearance  of  having  been  gnawed  away. 
The  eroded  parts  from  pockets,  Avhich  are  filled  with  a  grayish  pasty 
mass  similar  to  that  found  in  syphilitic  ulcers  of  the  mouth.  When 
this  mass  is  removed,  a  granulating  surface  is  exposed  which  bleeds 
easily  and  is  very  painful  to  the  touch.  The  patient's  breath  is  fetid, 
the  saliva  ropy  and  in  excess  of  normal.  Bloody  saliva  escapes  from 
the  mouth  during  sleep.  The  temperature  is  likely  to  be  about  101 
degrees. 

The  ulceration  seems  to  be  limited  to  the  areas  indicated,  although 
the  entire  mucous  membrane  of  the  mouth  may  be  red  and  swollen. 
The  submaxillary  lymphatics  are  involved  early.  Macroscopically  no 
pus   is  observed,   but  the  microscope   shows   pus   cells   in   abundance. 


^Thomas  L.  Gilmer :     Acute  Ulcerous  Gingivitis,  Dental  Review,  1916,  xx,  459. 


380 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Dr.  Gilmer  has  studied  the  bacteriology  and  Dr.  Ruth  Tunnicliff,  who 
made  the  cultures,  found  the  bacillus  fusiformis  and  spirilla  to  be 
the  predominating-  organisms   in  every  case. 

Gingivitis  Caused  by  Deposits  of  Salivary  Calculus.  Deposits 
of  salivary  calculus  upon  the  teeth  cause  inflammation  and  destruction 
of  the  gingivae.  If  the  deposits  are  neglected,  new  accretions  impinge 
upon  the  deeper  tissues  and  gradually  destroy  peridental  membrane, 
alveolar  process  and  gum  tissue.  As  a  rule,  all  of  the  tissue  adjacent 
to  the  root  is  destroyed  as  the  case  progresses,  but  without  the 
formation  of  a  pocket  (Fig.  335).  This  condition  is  thus  to  be  dif- 
ferentiated from  chronic  suppurative  pericementitis,  in  which  the 
characteristic  feature  is  the  detachment   of  the  peridental  membrane 


Fig.    335.  Fig.    336. 

Fig.  335.  Sketch  illustrating  destruction  of  the  gingivae  by  a  deposit  of  salivary 
calculus  on  the  labial  surface  of  the  lower  incisor,  also  a  more  extensive  deposit  on  the 
lingual  surface  of  the  same  tooth,  which  has  destroyed  the  gingivae  and  also  a  consider- 
able portion  of  the  peridental  membrane,  alveolar  process  and  gum. — G.  V.  Black. 

Fig.  336.  Sketch  illustrating  a  deposit  of  serumal  calculus  under  the  free  gingiva 
on  the  labial  surface  of  the  enamel  of  a  lower  incisor  tooth. — G.  V.  Black. 


and  the  formation  of  a  pus  pocket  along  the  side  of  the  root.  There 
is  often  a  little  suppuration  where  the  deposit  is  in  contact  with  the 
soft  tissue.  The  teeth  gradually  become  loose  from  lack  of  attach- 
ment and  eventually  are  lost. 

Gingivitis  Caused  by  Deposits  of  Serumal  Calculus. — Serumal 
calculus  may  be  deposited  on  the  enamel  of  the  tooth  close  to  its 
neck,  under  the  gum  margin.  These  deposits  will  be  found  in  the 
mouths  of  about  15  per  cent  of  adults.  The  elements  for  the  deposit 
are  brought  by  the  serum  which  is  constantly  exuded  from  this 
mucous  membrane,  hence  the  jiame — serumal  calculus  (Fig.  336). 
Its  presence  causes  inflammation  of  the  overlying  soft  tissue  which 
is    usually   deeper   red   than   normal,   and   the   gingival   margins   may 


INFECTIONS  OF  THE  TEETH.  381 

be  thickened  and  will  bleed  from  the  slightest  irritation.  Suppuration 
eventualy  occurs  and  invades  the  peridental  membrane,  causing  its 
detachment  from  the  root.  If  the  margin  of  the  gum  is  retracted, 
the  dark  brown  or  black  deposit  may  be  seen  on  the  tooth. 

Gingivitis  Due  to  Injuries.  The  gingivae  are  subject  to  many 
slight  injuries  and  to  often  repeated  or  continuous  slight  irritations. 
Those  conditions  which  result  in  the  impaction  of  food  between  the 
teeth  are  the  most  serious.  Often  the  extraction  of  a  tooth  will 
result  in  a  slight  movement  of  neighboring  teeth,  thus  permitting 
food  to  become  wedged  into  the  interproximal  spaces,  injuring  the 
gingivae.      Margins  of  artificial  crowns  or  fillings  often  act  as   con- 


Fig.  337.  Jaw-bone  showing  various  degrees  of  absorption  as  tlie  result  of  chronic 
pyorrhea  alveolaris.  The  site  of  the  second  right  molar  shows  but  a  shallow  depres- 
sion, while  that  of  the  third  molar  of  the  same  side  is  a  little  deeper.  The  site  of  the 
second  molar  on  the  left  side  shows  separate  sockets  for  the  two  roots,  but  the  sockets 
are  very  wide — especially  at  their  borders.  The  incisor  region  shows  almost  normal 
sockets,  while  behind  the  right  first  bicuspid  is  shown  the  condition  that  normally  re- 
sults after  the  removal  of  a  tooth. — Prom  a  specimen  In  the  Washington  University 
Medical  School. 

tinuous  irritants.  All  of  these  things  pave  the  way  for  infection 
and  suppuration,  and  the  deeper  tissues  are  usually  involved  sooner 
or  later.  ^i 

Chronic  Suppurative  Pericementitis.  (So-Called  Pyorrhea 
Alveolaris.)  The  essential  characteristic  of  this  disease  is  a  pus 
pocket  along  the  side  of  the  root  of  a  tooth.  It  is  always  preceded 
by  a  gingivitis  and  there  is  a  progressive  destruction  of  the  peridental 
membrane  toward  the  apex  of  the  root,  with  a  tendency  to  spread  very 
slowly  around  the  root.  Noyes^"  has  recently  shown  that  the  principal 
route  of  travel  of  the  infections  beginning  in  the  gingivae  is  by  way 
of  the  perivascular  lymphatics.     As  the  blood  vessels  of  the  peridental 


lOF.    B.    Noyes :      Studies   of   the   Pathology   of   the    Peridental    Membrane.      Journal 
National  Dental  Assn.,  April,  1917,  375. 


382 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


membrane  run  for  the  most  part  parallel  to  the  long  axis  of  the 
tooth,  this  would  explain  the  clinical  observation  that  these  pockets 
progress  in  depth  more  rapidly  than  laterally  around  the  root.  Ging- 
ivitis caused  by  deposits  of  serumal  calculus  and  that  caused  by 
injuries  are  the  most  frequent  forerunners.  In  a  limited  number  of 
cases,  constitutional  causes  may  be  responsible  for  the  preceding 
gingivitis.  It  seems  quite  probable  that  several  chronic  systemic  dis- 
eases may  develop  toxins  which  have  an  affinity  for  the  gingivae,  as 
has  lead,  bismuth,  mercury,  etc. 

In  any  case,  there  is  sufficient  inflammation  of  the  gingivae  to 
permit  a  pyogenic  infection  and  the  deeper  tissues  become  involved 
and  destroyed.  The  peridental  membrane  is  cut  away  from  the  sur- 
face of  the  root,  the  cementum  being  thus  denuded.  The  principal 
fibers  of  the  peridental  membrane,  which  serve  to  attach  the  root  to 
the  bone,  are  destroyed,  and  later  the  portion  of  bone  to  which  these 


Fig.  338.  Reproduction  of  radiograph  sliowing  extensive  destruction  of  the  bone 
and  alveolar  process  about  lower  bicuspid  and  molar  teeth  in  a  case  of  chronic  sup- 
purative pericementitis. — G.   V.   Black,. 


fibers  were  attached  disappears  either  by  absorption  or  suppuration 
(Fig.  338).  The  cementum  becomes  saturated  with  pus  and  the  prod- 
ucts of  the  suppurative  process.  Deposits  of  serumal  calculus  may 
occur  on  the  surface  of  the  root  and  cause  additional  irritation.  .  There 
is  no  more  likelihood  that  these  pockets  will  heal  than  there  is  of 
reattachment  of  the  soft  tissues  to  the  root  end  in  chronic  alveolar 
abscess.  The  tendency  is  for  more  and  more  of  the  peridental  mem- 
brane to  be  gradually  destroyed.  These  cases  tend  to  spread  to 
neighboring  teeth,  not  as  much  by  direct  involvement  of  the  soft 
tissue  as  by  causing  slight  movements  of  the  teeth,  thus  permitting 
food  to  wedge  between  them  and  irritate  the  gingivae. 

The  tissue  forming  the  pocket  is  a  granulating  connective  tissue, 
the  thin-walled  blood  vessels  of  which  are  easily  penetrated  by  the 
organisms  which  may  be  gTOwing  within  the  pocket.  This  consti- 
tutes the  systemic  danger.  Some  years  ago  it  was  thought  that  this 
condition  in  the  mouth  was  the  result  of  gout,  rheumatism,  and  other 


INFECTIONS  OF.  THE  TEETH.  383 

conditions.  It  seems  now  as  though  the  reverse  is  true,  that  these 
systemic  diseases  often  result  from,  instead  of  being  the  cause  of, 
the  mouth  condition. 

Pus  is  formed  within  the  pocket  almost  constantly  in  some  cases, 
intermittently  in  others.  Digital  pressure  will  cause  it  to  exude  at 
the  gum  margin.  The  cervical  lymphatics  may  be  involved;  there 
may  be  a  slight  rise  of  temperature.  There  is  an  excessive  flow 
of  saliva,  often  drooling  during  the  night. 

As  a  rule  there  is  little  or  no  complaint  of  pain  in  these  cases. 
As  the  pockets  get  deeper,  the  teeth  become  loose  and  are  likely  to 
be  tender  to  the  stress  of  mastication.  Occasionally  the  pus  formed 
will  penetrate  the  overlying  tissue  instead  of  being  discharged  along 
the  side  of  the  root,  and  an  abscess  will  result.  This  is  called  a 
lateral  alveolar  abscess,  and  should  be  distinguished  from  the  true 
alveolar  abscess  occurring  at  the  end  of  the  root.  These  lateral 
abscesses  are  accompanied  by  the  symptoms  of  an  acute  suppuration. 


V 


Pig.  339.  A  pair  of  special  explorers  for  measuring  the  depth  of  pus  pockets.  A 
millimeter  scale  is  cut  in  the  blades.  It  is  not  necessary  to  see  the  blade  while  in  the 
pocket  to  make  a  sufficiently  accurate  reading  ;  the  serum  within  the  pocket  will  adhere  to 
the  blade  and  the  reading  may  be  made  after  the  instrument   is  removed. — G.   Y.   Black. 

The  extent  of  the  detachments  of  the  peridental  membrane  may 
be  determined  by  using  a  thin  flat  blade  with  a  smoothly  rounded  end 
(Fig.  339).  Such  an  instrument  may  be  passed  alongside  the  root 
to  the  depth  of  the  pocket.  Radiographs  will  show  the  destruction  of 
the  bone  of  the  alveolar  process  in  all  cases  in  which  the  depth  of 
the  pocket  is  below  the  level  of  the  margin  of  the  bone. 

OSTEITIS  OR  INFLAMMATION  OF  THE  BONE. 

This  may  result  from  injury,  mineral  irritants,  septic  infection,  or 
certain  other  specific  infections.  When  bone  becomes  inflamed,  there 
is  an  increase  of  the  blood  supply  and  infiltration  of  leucocytes,  and 
later  on,  an  increase  of  the  bone  corpuscles  and  an  actual  loss  of  bone 
substance.  This  bone  destruction  is  caused  by  the  leucocytes  and 
occurs  probably  for  the  purpose  of  furnishing  room  for  the  inflamma- 
tory increase  of  the  blood  supply,  leucocytes,  and  fixed  tissue  cells. 
The  inflammation  may  clear  up,  leaving  the  bone  almost  normal,  it 


384 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


may  go  on  to  suppuration,  or  it  may  be  followed  by  a  necrosis.  It  may 
be  followed  by  rarefying  osteitis,  in  which  the  bone  becomes  so  porous 
as  to  be  soft  or  spongy,  or  a  sclerosis  in  which  the  mass  of  proliferating 
cells  are  converted  first  into  fibrous  tissue  and  then  into  very  hard  dense 
bone.  Bone  is  very  resistant  to  the  invasion  of  pus  organisms,  and 
when  bone  suppuration  occurs,  it  is  usually  confined  to  a  surface.  It 
may  be  intramedullary,  subperiosteal,  or  in  a  gradually  extending  cavity, 
but  the  suppurative  inflammation  will  rarely  involve  the  substance  of 
the  bone  to  any  depth.  If  it  does  do  so,  necrosis  of  the  involved  mass 
will  be  more  than  probable  (Fig.  340).  As  soon  as  death  of  this  mass 
of  bone  occurs,  the  inflammation  will  again  be  limited  to  a  surface  at  the 


Pig.  340.  X-ray  showing  a  chronic  bone  abscess  around  an  unerupted  deciduous 
second  molar,  which  has  in  turn  prevented  the  eruption  of  the  second  bicuspid.  Thp 
tooth  buds  of  the  bicuspids  lie  below  the  deciduous  molars. 


junction  of  the  living  and  dead  bone,  so  that  the  rule  that  suppuration 
of  the  bone  is  limited  to  a  surface  is  subject  to  few  exceptions  (Fig. 
342). 

If,  as  a  result  of  a  suppurative  inflammation  in  a  tooth  socket,  a 
part  of  the  root  becomes  denuded  by  destruction  of  the  pericementum, 
or  if  a  necrosis  has  resulted,  the  denuded  root  or  the  sequestrum  of  bone 
will  act  as  a  mechanical  irritant  which  will  prevent  healing.  Later 
the  lack  of  proper  drainage  may  help  to  continue  the  suppuration. 
Suppuration  always  presupposes  an  inflammatory  reparative  effort  on 
the  part  of  the  tissues,  for,  if  this  did  not  occur,  there  would  be  death 


INFECTIONS  OF  THE  TEETH. 


385 


of  the  tissues  without  the  formation  of  pus.  The  base  of  a  suppurating 
surface  is  so  crowded  with  leucocytes  and  rapidly  multiplying  fixed 
tissue  cells  that  they  form  an  extra  barrier  to  the  progress  of  the  in- 
fection.    This  inflammatory  wall  may  be  continuously  modified  or  de- 


Fig.  341.  Chronic  bone  abscess  around  the  roots  of  an  infected  tooth.  This  was  in  a 
young  girl,  who  had  submitted  to  several  external  operations  for  the  cure  of  a  discharg- 
ing fistula  below  the  mandible. 


Fig.   3-i2.     Inflammatory  destruction  of  the  maxillae,  due  probably  to  peridental  In- 
fection.— From  a  specimen  in  the  Washington  University  Medical  School. 

stroyed  on  its  exposed  surface,  but  at  the  same  time  is  added  to  on 
the  surface  in  contact  with  the  healthy  bone,  while  a  concurrent  absorp- 
tion of  the  bone  substance  takes  place.  It  is  by  this  process  that  an 
infection  at  the  apex  of  a  root  may  produce  a  definite  cavity  in  the 
body  of  the  bone  that  may  in  time  become  quite  extensive;  yet  at  no 


386  SURGERY  OF  THE  MOUTH  AND  JAWS. 

time  are  any  visible  bone  particles  thrown  off  (Fig.  341).  If  a  pro- 
gressive destructive  process  of  this  kind  were  to  occur  on  an  exposed 
surface,  it  might  be  called  an  ulcer.  In  the  jaw-bones  these  are  termed 
absorption  abscesses,  sometimes  incorrectly,  "dental  cysts."  The  pro- 
cess has  often  been  referred  to  as  caries  of  the  bone,  but  this  term 
is  better  reserved  for  cases  in  which  destruction  is  due  to  the  tubercle 
bacillus. 

The  bone  of  the  lower  jaw  is  much  denser  than  that  of  the  upper 
and  therefore  more  resistant. 

Absorption  abscesses  are  more  common  in  the  upper  jaw  and  attain 
larger  proportions.  When  an  absorption  abscess  does  occur  in  the 
lower  jaw,  it  is  more  apt  to  enlarge  at  the  expense  of  the  alveolar  bone 
which  surrounds  the  tooth  sockets,  occupying  the,  center  of  the  body, 
than  to  destroy  the  denser  outer  walls.  In  this  way  a  large  cavity  may 
form,  which  embraces  the  roots  of  several  teeth,  but  which  does  not 
materially  lessen  the  strength  of  the  bone.  In  many  cases  the  repar- 
ative effort  of  the  bone  granulations  would  be  sufficient  to  overcome 
the  infection,  were  it  not  for  the  presence  of  a  mechanical  irritant — 
such  as  a  piece  of  dead  bone,  an  exposed  denuded  root,  or  an  unerupted 
tooth. 

NECROSIS. 

The  destruction  of  bone  is  not  always  attained  by  the  slow  process 
just  described.  If  the  nutrition  of  any  area  of  bone  is  shut  off,  the 
part  involved  at  once  dies  without  any  immediately  apparent  change  in 
its  structure.  It  is  possible  that  the  death  of  bone  may  sometimes 
result  directly  from  the  action  of  bacterial  toxins,  but  probably  it  is 
nearly  always  due  to  a  shutting  off  of  the  blood  supply.  This  may 
result  from  direct  pressure  on  the  vessels  by  the  swelling  in  a  confined 
space,  from  a  tearing  of  the  vessels  when  the  periosteum  is  stripped  off 
by  accident  or  there  is  a  subperiosteal  collection  of  fluid,  or  from  septic 
thrombosis  of  the  interosseous  veins.  As  soon  as  an  area  of  bone  dies, 
the  leucocytes  begin  to  separate  it  from  the  live  bone.  If  the  necrosis 
has  not  been  caused  or  followed  by  a  septic  infection,  the  wall  of  granu- 
lations that  spring  up  at  the  plane  of  separation  will  remain  free  of  pus, 
and  the  dead  bone  may  remain  buried,  and  gradually  be  destroyed  by 
the  leucocytes  in  the  granulations  which  surround  it.  An  aseptic  ne- 
crosis seldom,  if  ever,  occurs  in  the  jaw-bones ;  the  plane  of  separation 
between  the  live  and  dead  bone  becomes  a  suppurating  surface,  and 
the  dead  bone  lies  in  an  abscess  cavity.  If  this  pus  does  not  find  a  free 
exit,  there  will  be  fever,  pain,  etc.,  just  as  in  any  other  undrained  ab- 
scess. It  is  not  the  dead  bone  that  causes  these  symptoms,  but  the 
accompanying  infection.     The  infection,  however,  will  persist  as  long 


INFECTIONS  OF  TFIE  TEETH. 


387 


as  the  dead  bone  remains  in  place.,  and  ample  drainage  must  be  pro- 
vided. 

The  necrosis  may  involve  a  part  of  or  the  whole  bone.  If  it  extends 
to  the  surface,  the  periosteum  will  almost  at  once  begin  to  form  a  shell 
of  new  bone,  and  all  exposed  surfaces  of  the  live  bone  will  be  covered 
with  a  wall  of  granulations.  In  this  way  the  dead  bone  will  come  to 
lie  in  a  bone  cavity  lined  with  granulations,  and  it  is  then  called  a 
sequestrum.  Except  when  freshly  cut  or  broken,  live  bone  never  pre- 
sents a  distinctly  hard  surface.  It  is  always  covered  with  a  thin  layer 
of  granulations  or  periosteum.  Dead  bone,  on  the  other  hand,  has  no 
such  covering",  and  its  surface  is  hard  and  rough  like  an  unpolished 
stone,  when  felt  with  a  probe.  Dead  bone  that  has  become  separated 
may  be  also  detected  by  the  x-ray  (Fig.  343). 


Fig.   343.      Necrosis  of  the  body  of  the  lower  jaw. 

Metallic  Poisoning. — Necrosis  of  the  bone  can  follow  any  local 
infection,  or  even  an  injury.  There  are  certain  mineral  poisons  that 
cause  an  inflammation  of  the  periosteum  and  bone,  and  this  is  very 
apt  to  be  followed  by  necrosis.  Among  these  poisons,  mercury,  phos- 
phorus, and  bismuth  are  the  most  prominent. 

Mercury. — This  is  carried  by  the  saliva  and  can  cause  a  destruc- 
tion and  inflammation  of  the  mucous  membrane,  periosteum,  and  bone. 
In  mild  ptyalism  the  gingiva  and  pericementum  become  sore,  but  in 
severe  mercury  poisoning,  which  was  formerly  seen  more  often  than 
at  present,  extensive  necrosis  of  the  bone  and  other  tissues  is  of  com- 
mon occurrence. 

Phosphorus. — Phosphorus  fumes  gain  entrance  to  the  pericemen- 
tum through  carious  teeth  or  from  irritation  of  the  gingivae,  and  cause 
at  first  a   painful  -inflammation   and  then   a   very   extensive  necrosis. 


388  SURGERY  OF  THE  MOUTH  AND  JAWS. 

In  the  earlier  days  of  the  manufacture  of  the  hicifer  match,  this  was 
common,  but  with  better  care  of  the  workmen's  surroundings  and  of 
their  teeth,  it  is  not  so  common  as  formerly. 

Bismuth. — This  is  probably  carried  by  both  the  blood  and  the 
saliva.  A  case  of  this  kind  came  into  the  St.  Louis  City  Hospital  in 
the  service  of  Dr.  Walter  Baumgarten.  In  this  patient,  two  months 
previously,  a  large  quantity  of  bismuth  paste  had  been  injected  into  the 
pleural  cavity.  The  pleural  sinus  had  healed  with  the  paste  in  place, 
but  the  man  was  much  emaciated  and  had  an  extensive  necrosis  of 
the  jaws.  He  died  shortly  afterward.  Other  such  cases  have  been 
reported.  Death  froni  sepsis,  starvation,  and  exhaustion  is  not  an 
uncommon  sequel  of  extensive  jaw  necrosis  from  phosphorus  or  mer- 
cury. 

Arsenic. — Arsenic  when  applied  locally  causes  necrosis  of  the 
tissue,  as  does  also  antimony. 

Peari.  Workers'  Disease. — Persons  working  at  the  manufacture 
of  mother-of-pearl  articles — such  as  buttons — are  subject  to  an  osteitis 
arising  in  the  diaphysis  next  to  the  epiphysis,  or  in  the  periosteum. 
According  to  DaCosta,  it  is  more  apt  to  affect  the  long  bones,  but  may 
occur  in  the  bones  of  the  face.  The  attack  begins  with  pain  and  a 
moderate  elevation  of  temperature,  which  lasts  several  weeks.  The 
condition  is  apt  to  recur  if  the  patient  returns  to  his  work.  It  is  a  con- 
densing osteitis,  and  undergoes  spontaneous  cure  if  the  patient  gives 
up  this  work. 

SPECIFIC  INFECTIONS  OF  BONE. 

Besides  the  ordinary  pus  infections,  there  are  a  number  of  specific 
infections  which  attack  the  jaw-bones. 

Syphilis.^This  may  affect  the  bones  either  as  a  thickening  of 
periosteum,  which  usually  occurs  after  the  secondary  lesions  have  dis- 
appeared, or  the  bone  substance  may  be  replaced  or  killed  by  gumma, 
which  is  a  tertiary  lesion.  As  the  periosteum  and  bone  become  infil- 
trated with  gummatous  tissue,  the  true  osseous  structures  may  become 
absorbed  or  necrosed.  When  gumma  breaks  down,  as  it  is  very  liable 
to  do,  a  defect  remains  corresponding  to  the  size  of  the  deposit, 
and  there  may  be  also  a  very  extensive  necrosis,  of  bone.  A  most 
common  site  of  gumma  is  in  the  hard  palate  and  bones  of  the 
nose.  It  is  usually  secondary  to  or  accompanies  gumma  of  the  super- 
imposed mucous  and  submucous  tissues,  and  this  accounts  for  the  per- 
forations of  the  palate  that  are  so  often  seen  in  late  syphilis  (Fig.  344). 

Actinomycosis. — Actinomycosis  (see  page  369)  is  an  infection 
with  the   ray   fungi,  which   causes   an   inflammation,   characterized  by 


INFECTIONS  OF  THE  TEETH. 


389 


the  formation  of  dense  granulations  which  have  Httle  tendency  to 
break  down  eii  masse,  but  they  develop  fistulae  from  which  are  dis- 
charged masses  of  fungi.  Actinomycosis  has  but  little  tendency  to 
affect  the  jaw-bones;  it  usually  occurs  in  the  soft  tissues  of  the  gums, 
floor  of  the  mouth,  and  in  the  cheek  and  neck  at  the  angle  of  the  jaw. 
The  infection,  entering  through  carious  teeth,  sometimes  affects  the 
bones;  then  there  may  also  be  extensive  necrosis  with  little  reproduc- 
tion of  new  bone.  There  will  be  the  usual  fistulae  discharging  their 
seropus  and  the  characteristic  yellow  granules.  The  disease  seems  to 
have  little  or  no  tendency  toward  spontaneous  recovery.  It  corresponds 
with  "lumpy  jaw"  in  cattle  and  probably  comes  most  often  from  putting 
infected  straws  in  the  mouth.  It  is  not  improbable  that  other  my- 
coses than  the  ray  fungi  are  at  times  parasitic  and  cause  symptoms 
and  lesions  similar  to  those  caused  by  actinomycosis. 


^r  M"^ 

"i^^E^^'  7^  oHm^l 

^K^j^^^^^H^J^^Hj^^lH 

Fig.  344.  Syphilitic  perforation  of  the  palate,  showing  partially  detached  piece  of 
necrotic  bone.  Photographed  for  this  book  by  courtesy  of  the  curator  of  the  Hunterian 
Museum,  London. 


Tuberculosis    of    Bone. — The    inflammation    that    accompanies 

an  infection  with  the  tubercle  bacillus  is  characterized  by  the  formation 
of  granulations  that  are  prone  to  break  down  en  masse,  leaving  cheese- 
like sloughs.  The  tubercle  bacillus  does  not  form  pus,  but  a  pus  infec- 
tion may  occur  secondarily.  In  comparison  with  the  number  of  people 
whose  mouths  are  exposed  to  infection  from  the  lungs,  tuberculosis 
of  the  jaw-bones  is  rather  rare,  and  an  infection  at  the  epiphysis  of 
the  mandible  extremely  so. 

A  bone  focus  leads  to  the  formation  of  a  cavity  which  will  con- 
tain granulations,  perhaps  a  caseous  material,  or  a  sequestrum.  The 
sequestra  in  tuberculous  osteomyelitis  rarely  completely  separate. 

Postfebrile  Osteitis. — Following  most  any  of  the  infectious  dis- 
eases, particularly  typhoid  fever,  there  may  result  a  chronic  osteo- 
myelitis which  may  be  followed  by  necrosis.  The  typhoid  bacilli  may 
accumulate  in  a  bone  and  immediately,  or  years  afterward,  on  some 
slight  provocation  start  an  active  process  that  ends  in  necrosis. 


390  SURGERY  OF  THE  MOUTH  AND  JAWS. 

There  are  other  rarer  specific  infections  that  affect  bone,  but  in 
all,  the  general  outline  of  the  process  is  the  same  as  in  those  that  have 
been  described.  There  is  an  inflammation  which  consists  in  an  in- 
creased blood  supply,  infiltration  with  leucocytes,  and  an  increase  of  the 
fixed  tissue  cells,  accompanied  by  a  destruction  of  the  bone  tissue  by  the 
leucocytes. 

ATROPHY. 

Atrophy  of  the  bone  is  a  diminution  of  the  amount  of  bony  matter 
without  change  of  structure.  This  comes  from  lack  of  use  and  is 
nowhere  better  illustrated  than  in  the  absorption  of  the  alveolar  pro- 
cess after  the  loss  of  teeth,  or  the  absorption  from  both  the  body  and 


Fig.   34.5.      Leontiasis  ossea.     Xote  the  slight  involvement  of  the  nasal  bones.      Pho- 
tographed for  this  book  by  courtesy  of  the  curator  of  the  Hunterian  Museum,  London. 

ramus  that  occurs  in  the  aged.  With  the  loss  of  teeth  there  is  a 
lessening  of  function  and  atrophy  of  muscles.  The  greatest  loss  of 
bone  is  at  the  angle  where  the  internal  pterygoid  and  masseter  are 
attached;  this  causes  the  apparent  increase  of  the  angle  seen  in  old, 
edentulous  mandibles. 

HYPERTROPHY. 

Hypertrophy  of  the  bone   is  an   abnormal  growth   in  size  and   is 
rarely  seen  in  the  jaws.     Atrophy  is  to  be  distinguished  from  lack  of 


INFECTIONS  OF  THE  TEETH.  391 

growth,  while  any  overgrowth  of  normal  tissue  may  be  spoken  of  as 
hypertrophy, 

TUMORS  OF  BONE. 

Bone  gives  rise  to  tumors,  both  malignant  and  benign,  but  primary 
tumors  of  the  bone  are  always  of  the  connective  tissue  type.  Carci- 
nomata  may  arise  in  the  bone,  due  to  a  metastasis,  or  they  may  grow 
into  the  bone  from  neighboring  epithelium.  The  latter  is  a  common 
occurrence  in  the  spread  of  a  carcinoma  from  the  gum  to  the  alveolar 
process.  Endotheliomata  may  arise  within  the  bone  from  the  con- 
tained lymphatics  or  blood  vessels, 

LEONTIASIS  OSSEA. 

Leontiasis  ossea  is  a  hypertrophy,  limited  to  the  bones  of  the  face, 
usually  beginning  in  the  maxillae.  The  cause  is  not  known.  Besides 
the  general  deformity,  it  causes  pressure  on  the  nerves  and  organs  of 
the   face.     Blindness   may   result    (Fig.    345). 


CHAPTER  XXVII. 

TREATMENT  OF  INFECTIONS  OF  THE  TEETH,   PERI- 
DENTAE.  MEMBRANES,  AND  MAXILLARY  BONES. 

Since  most  of  the  serious  infections  of  these  tissues  originate  in 
the  field  of  the  dentist,  it  is  important  that  every  possible  effort 
should  be  made  to  cut  these  cases  short  before  the  peridental  mem- 
brane becomes  involved.  Dental  caries  must  be  prevented  or  so  treated 
that  there  will  be  the  highest  possible  degree  of  pulp  conservation. 
This  calls  for  the  closest  cooperation  between  patient  and  dentist; 
better  care  by  the  patient,  more  frequent  and  more  thorough  examin- 
ations to  find  cavities  when  small,  and  the  greatest  care  in  the  tech- 
nique of  filling  operations.  Gingival  irritation  must  be  reduced  by 
better  cleanliness  by  the  patient,  and  keener  observation  and  improve- 
ment in  all  the  finer  technical  details  by  the  dentist. 

ACUTE  ALVEOLAR  ABSCESS. 

An  acute  alveolar  abscess  calls  for  the  same  treatment  as  any 
other  abscess — good  drainage  for  the  discharge  of  pus  and  to  relieve 
the  pain.  In  a  limited  number  of  cases,  especially  in  the  early  stages, 
provided  the  tooth  is  not  too  sore,  sufficient  drainage  may  be  secured 
through  the  root  canals  of  the  tooth,  by  opening  and  cleansing  of 
the  canals.  In  the  large  percentage  of  cases,  however,  and  in  all 
in  which  pus  may  be  palpated,  an  incision  should  be  made 
to  evacuate  the  pus.  The  center  of  the  incision  should  be  over 
the  point  of  greatest  tenderness.  As  a  rule,  the  incision  should  be 
made  within  the  mouth.  If  it  is  to  be  made  on  the  lingual  surface, 
posterior  to  the  bicuspid  teeth,  the  point  of  the  knife  should  be 
inserted  and  kept  close  to  the  bone  on  account  of  the  proximity  of 
the  lingual  nerve.  The  incision  should  be  made  parallel  to  the 
alveolar  process,  with  the  knife  held  obliquely  so  that  the  point  will 
cut  through  the  periosteum.  The  center  of  the  incision  should  be  over 
the  point  of  greatest  tenderness.  If  the  incision  is  to  be  made  on  the 
lingual  surface,  posterior  to  the  bicuspid  teeth,  the  point  of  the  knife 
should  be  inserted  and  kept  close  to  the  bone  on  account  of  the 
proximity  of  the  lingual  nerve.  The  incision  must  cut  through  the 
periosteum,  for  the  pus  is  at  first  subperiosteal  and  can  remain  so 
until  great  damage  is  done  to  the  bone.  If  the  pus  is  not  seen  to 
flow  after  this  incision,  the  knife  is  to  be  reinserted  at  the  middle 

392 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  393 

of  the  wound  with  the  edge  toward  the  bone,  and  the  periosteum 
incised  from  the  lower  to  the  alveolar  border  of  the  jaw.  It 
is  not  probable  that  both  cuts  of  this  crucial  incision  will  miss  a  sub- 
periosteal focus,  but  it  does  not  necessarily  follow  that  visible  pus  will 
be  liberated.  The  swelling  may  be  entirely  an  induration.  .As  sharply 
outlined,  well-marked  indurations  are  often  caused  by  the  more  viru- 
lent staphylococcus  and  streptococcus  infections,  it  is  important  that 
these  be  freely  drained,  for  any  one  of  them  may  be  an  early  stage  of 
fulminating  infection.  The  majority  will  subside  without  causing 
serious  trouble,  but  it  is  a  safe  rule  to  incise  every  such  induration, 
unless  seen  late  when  the  symptoms  are  subsiding.  Usually  a  well- 
executed  incision  will  initiate  convalescence,  though  it  may  be  followed 
by  some  reaction,  and  occasionally  the  infection  will  continue  to  spread 
in  spite  of  drainage.  After  the  opening  is  made,  a  self-retaining  rubber 
dam  or  tube  drain  should  be  carried  to  the  bottom  of  the  wound ;  and  if 


Fig.  346.  Showing  one  method  of  cutting  and  inserting  a  self-retaining  rubber 
dam  drainage. 

pain,  induration,  or  fever  persist,  hot  applications,  both  in  the  mouth 
and  externally,  should  be  used  frequently  (Fig.  3-16). 

The  immediate  after-treatment  consists  further  in  the  use  of  a 
weak  solution  of  permanganate  potassium,  or  any  mildly  antiseptic 
mouth  wash.  If  the  rubber  dam  reaches  to  the  bottom  of  the  wound, 
other  local  treatment  will  be  unnecessary.  However,  if  the  wound  is 
foul,  it  may  be  irrigated,  and  lightly  packed  with  gauze  saturated  with 
compound  tincture  of  benzoin.  Whether  or  not  the  wound  will  heal 
without  leaving  a  sinus  will  depend  entirely  upon  the  condition  within 
the  hone  and  not  on  local  after-treatment  of  the  wound  itself. 

If  there  is  dead  or  diseased  bone  or  a  piece  of  root  exposed  in  a 
bone  cavity,  it  is  probable  that  a  sinus  will  persist.  If,  after  an  infec- 
tion has  spread  beyond  the  alveolar  process,  it  is  decided  to  remove 
the  offending  tooth  or  roots,  we  believe  there  is  sound  reason  in  waiting 
for  the  acute  symptoms  to  subside  somewhat. 

In  many  cases,  where  rapid  extension  of  an  infection  has  followed 
the  extraction  of  a  tooth,  the  dentist  has  been  blamed  on  the  theory 


394  SURGERY  OF  THE  MOUTH  AND  JAWS. 

that  his  instruments  were  not  clean.  There  is  no  more  justice  in  this 
than  to  conclude  that  because  a  peritonitis  follows  an  appendectomy 
it  was  due  to  infection  introduced  at  the  operation.  The  infection 
from  a  tooth  root  spreads  from  near  the  apex  of  the  socket,  a  part 
rarely  directly  reached  by  the  jaws  of  the  extracting  forceps.  Both 
the  appendix  and  the  tooth  are  removed  because  they  are  diseased, 
and  the  diffuse  infection  that  may  result  is,  in  either  case,  due  partly 
to  trauma  of  the  operation  and  partly  to  a  lack  of  resistance  to  the 
infection.  If  in  the  presence  of  disaster  any  blame  is  to  be  attached 
to  the  operation,  it  must  rest  either  upon  the  technique  or  upon  the  time 
that  it  was  chosen.  In  the  extraction  of  teeth  there  is  not  much  choice 
in  the  selection  of  technique,  and  in  the  selection  of  time,  the  dentist, 
like  the  surgeon,  can  only  exercise  his  best  judgment. 

In  those  cases  in  which  the  effort  is  to  be  made  to  save  the  tooth, 
the  dead  pulp,  which  caused  the  abscess,  should  be  removed  as  soon 
as  the  acute  symptoms  have  subsided.  This  should  be  done  under 
the  strictest  asepsis.  It  should  be  remembered  that  practically  all 
cases  of  acute  alveolar  abscess  are  followed  by  the  chronic  form 
unless  the  dead  pulp  is  promptly  removed.  The  acute  abscess  does 
not,  as  a  rule,  destroy  the  peridental  membrane  about  the  end  of 
the  root;  the  infection  passes  through  this  tissue,  and  the  abscess  is 
mostly  within  the  bone.  Later  on,  the  continued  reinfection  of  the 
area  from  the  pulp  tissue  causes  the  destruction  of  the  peridental 
membrane. 

CHRONIC  ALVEOLAR  ABSCESS. 

With  rare  exceptions  a  sinus  extending  into  the  jaw-bone  is  simply 
an  emergency  drain,  created  and  maintained  for  the  purpose  of  carry- 
ing off  a  pathological  excretion,  and  it  will  persist  as  long  as  this 
abnormal  excretion  continues ;  therefore  the  treatment  of  the  sinus 
is  the  treatment  of  the  pathological  condition  that  causes  it.  In  other 
parts  of  the  body  a  sinus  will  often  persist  on  account  of  the  scar 
that  lines  the  wall,  or  on  account  of  disease  of  its  wall.  However, 
with  the  exception  of  malignant  growths  and  actinomycosis,  we  have 
never  seen  a  sinus  about  the  jaws  that  was  not  compensatory  for 
some  pathological  condition  at  its  deeper  end,  and  no  amount  of  operat- 
ing on  or  treatment  of  the  sinus  itself  will  cure  it.  We  have  seen 
cases,  in  which  as  many  as  four  operations  had  been  done  on  the 
soft  tissues  of  the  face  without  effect,  that  at  once  closed  on  the 
removal  of  the  diseased  root.  The  common  causes  are ;  a  root  ex- 
posed in  an  affected  bone  cavity;  an  infected  cavity  surrounded  by 
soft  bone,  or  too  large  to  close  by  granulations  or  prevented  from 
doing  so  by  a  piece  of  dead  bone;  or  an  infection  around  an  uneruptecl 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  395 

tooth.  The  last  condition  is  not  an  uncommon  cause  of  persistent 
fistula  in  the  gum  of  a  person  who  has  apparently  lost  all  of  his 
teeth.  Disease  of  the  maxillary  antrum  may  sometimes  drain  through 
a  sinus  leading  into  the  mouth. 

In  determining  the  treatment  of  a  chronic  alveolar  abscess,  it  is 
of  the  utmost  importance  that  one  should  know  to  what  extent  the 
cementum  of  the  root  has  been  denuded  of  its  peridental  membrane. 
This  should  decide  at  once  whether  or  not  the  tooth  is  to  be  extracted. 
Radiographs  should  be  made  of  the  majority  of  cases  and  will  often 
clearly  show  that  there  is  no  hope  of  saving  the  tooth.  If  there  is 
a  sinus,  the  Gilmer  sharp  steel  probe  should  be  inserted  and  the  con- 
ditions about  the  root  end  explored  (Fig.  347).  When  the  end  of 
the  probe  reaches  the  root,  it  may  be  moved  in  first  one  direction, 
then  another,  until  the  contour  of  the  root  and  the  extent  of  the 
destruction  of  the  surrounding  tissue  is  determined.  If  it  is  found, 
as  is  often  the  case,  that  the  root  end  projects  into  a  cavity  in  the 


c 


Fig.  347.  A.  The  sharp,  stiff  steel  probe  first  suggested  by  Dr.  Thomas  L.  Gnuier. 
With  such  a  probe  one  can,  with  a  little  experience,  easily  differentiate  the  enamel  of 
an  impacted  tooth,  the  root  of  a  tooth,  necrosed  tone,  or  the  softened  bone  in  chronic 
osteitis.  This  probe  should  be  used  to  explore  every  sinus  about  the  mouth.  B,  soft  blunt 
end  silver  probe  for  following  tortuous  sinuses. — G.  V.  Black. 

bone,  there  is  no  hope  of  a  cure,  so  long  as  the  root  end  remains; 
either  the  tooth  must  be  extracted,  or  the  root  end  must  be  resected. 
The  operation  of  resection  is  most  likely  to  be  successful  when  per- 
formed on  the   upper  front  teeth. 

Under  a  local  anesthetic  a  semilunar  incision  is  made  several 
centimeters  long  with  its  center  corresponding  to  the  diseased  root. 
The  concavity  of  the  incision  is  toward  the  root  apex.  This  incision 
extends  through  the  periosteum,  and  all  of  the  included  tissues  are 
raised  from  the  bone  in  the  form  of  a  flap  and  held  with  a  small 
retractor.  Sponging  is  done  by  an  assistant,  with  small  balls  of  wet 
cotton,  and  if  the  field  is  obscured  by  bleeding,  this  may  be  con- 
trolled by  the  application  of  adrenalin  chlorid  solution.  It  is  probable 
that  a  bone  cavity  will  be  exposed.  The  exposed  root  is  amputated 
by  means  of  a  cross-cut  fissure  bur  or  a  small  plain  drill,  the  latter 
being  Dr.  Gilmer's  custom.  Occasionaly  it  is  necessary  to  cut  through 
the  outer  plate  of  bone  to  reach  the  cavity.     The  cavity  or  soft  spot 


396  SURGERY  OF  THE  MOUTH  AND  JAWS. 

is  to  be  cleaned  out  with  a  curette  or  bur.  After  the  operation  the 
cavity  is  to  be  Hghtly  packed  with  antiseptic  gauze  for  a  few  days, 
after  which  no  further  treatment  other  than  a  mouth  wash  is  needed. 
It  has  been  recommended  to  remove  the.  flap  of  soft  tissue  that  was 
raised  in  exposing  the  cavity,  but  we  are  very  certain  that  this  is 
not  good  practice.  When  the  flap  is  left,  its  periosteal  surface  is 
drawn  into,  and  helps  fill,  the  bone  gap  with  bone  tissue,  the  whole 
being  covered  with  normal  mucous  membrane.  If  the  flap  is  removed, 
the  bone  cavity  can  be  lined  only  with  granulations  which  result  in 
scar  tissue  surface;  and  if  a  deep  depression  persists,  it  is  a  catch-trap 
for  food  particles.  If  the  granulations  lining  a  bone  cavity  or  cover- 
ing a  surface  are  unhealthy,  they  should  be  removed  along  with  any 
diseased  bone,  and  the  cavity  treated  as  already  outlined. 

Before  performing  this  operation  the  dead  pulp  should  have  been 
removed  and  the  root  canal  sterilized  and  filled.  All  such  cases  should 
be  followed  up  by  radiographic  examination  in  six  months  or  a  year 
to  determine  whether  or  not  a  blind  abscess  remains. 


Fig.   348.      Jaw  of^aii  old  person,  showing  an  unerupted  third  molar  tooth. 

NECROSIS, 

It  is  not  the  dead  bone  that  is  to  be  treated,  but  the  tissues  that 
surround  it.  Sepsis  is  usually  the  cause,  and  it  always  accompanies 
necrosis  of  the  jaw-bone.  The  treatment  must  cover  four  points:  the 
elimination  or  control  of  the  cause,  if  it  is  still  active ;  the  establishment 
of  free  drainage  of  infected  areas ;  the  support  of  the  general  condition 
of  the  patient;  and  at  the  proper  time,  the  removal  of  the  dead  bone. 

If  the  necrosis  follows  an  injury — such  as  the  splintering  of  the 
lower  jaw-bone  by  a  bullet  or  in  a  comminuted  fracture — it  is  usually 
not  mechanical  violence  that  causes  the  necrosis,  but  the  fact  that  an 
avenue  of  infection  has  been  opened  which  can  destroy  the  remaining 
source  of  nutrition  of  bone  spiculae  that  might  otherwise  have  survived 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  397 

the  original  injury.  Therefore,  in  all  comminuted  fractures  and  in 
gunshot  injuries,  free  dependent  drainage  from  the  site  of  the  bone 
injury  should  be  immediately  established,  but  only  such  pieces  of  bone 
as  have  absolutely  no  periosteal  attachment  should  be  removed  at  this 
time. 

If  the  necrosis  results  from  an  infection,  or  an  infection  preceded 
by  a  mineral  irritant,  this  must  be  dealt  with.  The  fundamental 
treatment  of  infection  is  drainage.  Not  only  the  pockets  in  the 
diseased  tissues  should  be  drained,  but  the  infectious  material 
that  collects  in  the  mouth  should  be  rapidly  removed.  The  presence 
of  fever  and  other  signs  of  sepsis  will  indicate  the  necessity  of  drainage, 
while  local  swellings  and  indurated  or  soft  points  of  tenderness  or  pain 
will  indicate  the  site  that  is  to  be  drained.  The  drainage  must  be  free, 
and  as  many  incisions  should  be  made  as  are  necessary.  It  may  be 
that  there  are  several  distinct  pockets,  or  just  one  space  which  can  be 
drained  through  one  well-placed  opening.  When  possible,  these  in- 
cisions should  be  made  from  the  inside  of  the  mouth.  The  lingual 
nerve  lies  to  the  inner  side  of  the  body  of  the  mandible  below  the  molar 
teeth,  separated  from  the  periosteum  only  by  the  mylohyoid  muscle.  It 
might  be  cut  by  a  badly  planned  incision. 

When  the  infection  extends  around  the  lower  border  of  the  mandi- 
ble, intraoral  incisions  are  rarely  efficient.  External  incisions  may  be 
made  along  the  lower  border  of  the  jaw  which  will  leave  no  permanent 
disfigurement,  and  one  or  several  external  incisions  should  be  made 
here  wherever  pus  tends  to  collect  at  this  site.  The  facial  artery 
crosses  the  body  of  the  lower  jaw  about  2  centimeters  in  front  of  the 
angle,  and  a  motor  branch  to  the  depressor  muscles  of  the  mouth 
crosses  obliquely  by  several  filaments  over  a  space  of  2  centimeters  in 
front  of  the  artery.  If  prepared  to  tie  it,  there  is  no  objection  to  cutting 
the  artery,  but  the  whole  nerve  should  not  be  cut  if  avoidable.  An  in- 
cision over  the  nerve  may  be  safely  made  if  only  the  skin  and  super- 
ficial fascia  are  cut  with  a  knife,  and  the  other  tissues  are  penetrated 
with  a  sharp-nosed  artery  forceps ;  and  the  opening  is-  completed  by 
spreading  the  blades  (Hilton's  method).  If  a  depressed  scar  should 
result,  the  scar  can  be  excised  later,  and  all  trace  practically  eliminated 
by  careful  suturing.  Deep,  narrow  incisions  should  be  kept  patent 
with  a  rubber  dam  or  tube  drain;  wide  ones  may  be  lightly  packed. 
Drainage  from  the  mouth  cavity  is  accomplished  by  the  frequent  use 
of  a  mouth  wash,  if  the  patient  can  use  it  properly,  or  by  irrigations 
from  a  douche  can  with  a  soft  catheter  passed  into  the  mucous  spaces 
of  the  fornices  and  below  the  tongue.  If  the  excretion  is  excessive,  the 
patient  should  be  turned  on  his  side  so  that  it  will  run  from  the  mouth 
in  preference  to  being  swallowed. 


398  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Regardless  of  what  incisions  are  necessary,  they  should  be  suffi- 
ciently free  to  gain  all  that  is  to  be  accomplished  by  drainage.  In 
critical  cases,  when  life  seems  to  be  at  stake,  much  of  the  septic  ab- 
sorption can  be  prevented  by  deep,  extensive  incisions  that  parallel  or 
enter  the  inflamed  areas,  even  before  any  distinct  pockets  of  pus  have 
formed.  But  in  just  such  cases  the  drainage  should,  if  possible,  be 
established  at  one  thorough  operation ;  for  the  repeated  hemorrhage  and 
shock  of  several  operations  might  be  the  determining  factor  of  fatality. 

The  source  of  metallic  poisons  should  be  cut  off  as  soon  as  possible. 
A  deposit  of  bismuth  paste  in  a  cavity  should  be  washed  out  with  olive 
oil,  and  the  bowels  kept  freely  open.  A  phosphorus  worker  should 
leave  his  work  and  begin  sulphate  of  copper  internally  until  the  limit 
of  tolerance  is  established.  The  sulphate  of  copper  converts  the  free 
phosphorus  into  the  insoluble  copper  phosphate.  Whether  this  would 
have  a  beneficial  effect  on  the  phosphorus  already  deposited  in  the  bone 
and  periosteum  may  be  doubtful,  but  it  would  render  inert  any  free 
phosphorus  in  the  circulation. 

Mercury  necrosis  is  secondary  to  the  ulceration  of  the  mucous 
membrane,  the  saliva  being  a  carrier  of  mercury.  Hydrogen  peroxid 
solution  is  probably  the  best  local  application  to  limit  infection  in  the 
presence  of  mercurial  irritation.  The  use  of  potassium  iodid  inter- 
nally has  been  recommended  to  eliminate  the  drug,  but  according  to 
Cushney,  its  efficiency  has  not  yet  been  established  beyond  dispute. 

In  most  cases  of  extensive  necrosis  of  the  jaw,  there  is  a  profound 
depression  due  partly  to  sepsis,  partly  to  pain,  lack  of  food,  and  in- 
ability to  sleep.  As  already  described,  sepsis  is  to  be  combated  chiefly 
by  drainage;  one  would  hesitate  to  use  vaccines  in  a  profound  sepsis. 
Relief  of  pain  and  proper  feeding  are  also  important.  Most  of  the  pain 
will  be  relieved  by  proper  incisions ;  these  may  be  supplemented  by  an 
anodyne  or  a  hypnotic,  but  they  are  not  to  be  substituted  for  the  in- 
cisions. Frequent  liquid  feeding,  a  little  strychnin,  alcohol,  or  other 
stimulant,  with  rest  in  bed,  are  to  be  resorted  to  in  every  case  of  any 
gravity.  These  patients  sometimes  linger  for  many  weeks  and  then 
die  of  exhaustion.  When  this  occurs,  one  cannot  but  feel  that  possibly 
something  else  might  have  been  done  that  would  have  helped  to  tide 
the  patient  over. 

Removal  of  the  Sequestrum. — Though  a  constant  mechanical  ir- 
ritant, the  necrosed  bone  is  not  to  be  removed  until  it  has  been  cut  loose 
from  the  living  bone  by  the  leucocytes,  because,  until  this  has  occurred, 
it  is  practically  impossible  to  determine  the  line  of  cleavage  between 
the  two.  After  the  sequestrum  is  cut  loose,  it  has  only  to  be  lifted  out 
of  its  bed.  It  may  be  necessary  to  make  an  incision  through  the  soft 
tissues  and  possibly  through  some  bone  before  its  bed  is  sufficiently 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  309 

exposed  to  allow  of  removal.  Usually  from  three  weeks  to  three 
months  will  elapse  before  a  sequestrum  is  ready  to  be  removed.  Tuber- 
culous bone  disease  is  an  exception  to  the  rule  of  waiting  until  the 
sequestrum  is  loose.  Here  the  dead  bone  is  to  be  removed  with  a 
curette,  as  it  is  not  thrown  off  cleanly  as  are  other  sequestra. 

If  the  necrosis  is  the  result  of  syphilis,  even  if  loose,  the  seques- 
trum should  not  be  disturbed  until  the  patient  is  fully  under  the  influ- 
ence of  antisyphilitic  medication,  as  a  mechanical  injury  is  liable  to  cause 
an  extension  of  the  infection. 

If  the  full  thickness  of  the  jaw  becomes  necrosed,  the  sequestrum  is 
not  to  be  removed  until  enough  new  bone  has  been  deposited  by  the 
surrounding  periosteum  to  form  a  rigid  casing  to  the  gap.  Otherwise 
artificial  mechanical  support  will  have  to  be  provided ;  for  the  periosteum 
at  this  site  would  crumple  up,  and  a  deformity  would  result  proportionate 
to  the  extent  of  the  necrosis.  The  sequestrum  should  be  left  in  place 
to  serve  as  a  splint  to  the  new-forming  bone  and  should  not  be  removed 
for  three  months.  It  has  been  observed  that  where  the  whole  mandible 
dies  it  will  regenerate,  but  later  the  new  jaw  may  atrophy,  probably 
because,  containing  no  teeth,  it  lacks  function. 

CHRONIC  BONE  ABSCESS. 

While  an  agency  of  infection  is  still  aggressive,  we  can  do  little  but 
provide  drainage  and  care  for  the  patient  until  sufficient  antitoxins  are 
furnished  naturally  or  artificially  to  modify  or  overcome  it.  In  most 
parts  of  the  body  this  is  all  that  is  necessary,  for,  as  soon  as  the  infec- 
tion is  neutralized,  healing  progresses  without  interruption.  In  bone 
abscesses  there  are  mechanical  hindrances  that  handicap  the  reparative 
process  to  such  an  extent  that  surgical  intervention  is  often  necessary. 

When  a  defect  in  the  soft  tissues,  due  to  actual  loss  of  substance, 
heals,  we  often  speak  of  the  cavity  having  been  filled  with  granulations. 
This  is  not  the  case,  however,  as  the  granulating  surface  is  ordinarily 
never  more  than  a  few  millimeters  thick.  What  happens  is  that  the 
older  and  deeper  cells  are  soon  converted  into  scar  tissue  which  forms 
a  contracting  layer  attached  at  its  edges  to  the  skin  or  mucous  mem- 
brane that  borders  the  wound.  As  this  scar  layer  decreases  in  size, 
it  draws  on  the  skin  or  mucous  borders  like  a  puckering  string,  which 
lessens  the  circumference  of  the  wound ;  it  also  draws  the  borders  down 
toward  the  floor  of  the  wound  and  the  tissues  of  the  floor  up  toward 
the  surface,  which  lessens  the  depth.  As  a  result,  when  final  healing 
takes  place,  it  will  be  found  that  the  edges  are  slightly  depressed,  and 
the  amount  of  scar  remaining  is  but  a  very  small  fraction  of  the  original 
size  of  the  defect.  What  has  happened  is  that  the  defect  is  obliterated, 
not  by  being  filled  with  granulations,  but  by  the  granulations  drawing 


400 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


in  the  neighboring  tissues.  Shallow  bone  cavities  heal  by  having  the 
neighboring  soft  tissues  drawn  into  them,  but  the  natural  healing  of  a 
deep  cavity  with  a  narrow  outlet  can  occur  only  by  being  actually  filled 
by  the  granulations  (Fig.  349).  This  is  an  extremely  slow  process,  for 
after  a  certain  time  contraction  in  the  deep  scar  layer  of  a  healing  sur- 
face interferes  with  the  nutrition  of  the  superficial  granulations;  they 
become  indolent  and  easily  aflfected  by  even  mild  infections.  We  may 
burn  or  scrape  the  indolent  and  diseased  granulations  down  to  healthy 
tissue,  but  if  the  circumstances  remain  the  same,  the  same  condition  in 
the  granulations  will  recur.  It  is  for  the  reasons  cited  that  abscess 
cavities  in  the  substance  of  the  bone  heal,  if  at  all,  very  slowly,  and  for 


^..  -iV^J 


Fig.    349. 


Fig.    350. 


Fig.  349.  Diagram  of  an  infected  bone  cavity  in  the  lower  jaw  with  a  sinus  dis- 
charging through  the  skin  in  the  submaxillary  region;  also  of  a  bone  abscess  in  the 
upper  jaw  under  the  mucoperiosteal  lining  of  the  antrum. 

Fig.  350.  Diagram  of  the  condition  shown  in  the  preceding  figure,  after  the  re- 
moval of  one  wall  of  the  abscess  in  the  lower  jaw,  and  after  removing  one  wall  of  the 
abscess  in  the  upper  jaw  and  amputation  of  the  tooth  root  that  extended  into  the  cavity. 

the  same  reasons  the  surgical  treatment  of  chronic  bone  abscesses  is 
their  immediate  obliteration.  The  best  plan  of  doing  this  is  to  bring 
one  granulating  surface  in  direct  contact  with  another  granulating  or 
raw  surface,  so  that  healing  will  occur  between  them.  When  this  can- 
not be  done,  the  slight  pressure  of  gauze,  wax,  or  any  other  non-irri- 
tating substance  seems  both  to  protect  and  to  stimulate  the  cells  to  the 
extent  that  they  are  able  to  cope  with  most  subacute  or  chronic  infec- 
tions. 

The  most  powerful  antiseptic  we  have  at  our  disposal,  one  upon 
which,  consciously  or  unconsciously,  we  are  almost  entirely  dependent 
for  overcoming  every  infection,  is  the  activity  of  the  living  tissue  cells. 
Our  hope  of  eliminating  infection  from  such  cavities  is  not  the  use  of 
chemical  antiseptics,  but  in  maintaining  the  health  of  the  exposed  cells. 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  401 

Before  attempting  to  obliterate  a  bone  cavity,  any  mechanical  irri- 
tant— such  as  a  tooth,  root,  sequestrum,  spongy  bone,  or  diseased  gran- 
ulations— should  be  removed,  but  this  does  not  necessarily  apply  to  the 
protective  granulations  that  line  the  ordinary  chronic  bone  abscess. 
Cavities  in  the  alveolar  process  will  usually  heal  after  the  tooth  is 
removed.  A  light  packing  of  gauze  will  keep  the  granulations  in  a 
healthy  condition.  If  the  cavity  extends  deeper  in  the  body  of  the 
bone,  it  will  have  to  be  obliterated  artificially.  One  method  of  doing 
this  is  to  fill  it  with  some  substance;  another  is  to  remove  one  lateral 
wall,  thus  converting  a  deep  narrow  space  into  a  wide  shallow  one 
into  which  the  soft  tissue  can  be  easily  drawn   (Fig.  350). 

Obliteration  of  a  Cavity  with  Bone  Plombe. — Artificial  sub- 
stances made  to  fill  cavities  resulting  from  the  destruction  of  bone  are 
sometimes  termed  "bone  plombe."  There  are  two  kinds  of  fillings :  the 
absorbable  made  from  an  animal  tissue  or  animal  wax — to  which  class 
belongs  the  bone  wax  of  Mosetig-Moorhof ;  and  the  very  slightly  ab- 
sorbable— to  which  latter  belongs  Beck's  bismuth  paste. 

A  formula  of  Mosetig's  filling  is : 

Spermaceti,  30  parts. 
Oil  of  sesame,  15  parts. 
Crystal  iodoform,  10  parts. 

In  the  mouth  the  iodoform  is  objectionable,  and  some  other  mildly 
antiseptic  substance — such  as  pulverized  colloidal  silver,  insoluble  in 
oil  or  wax,  xeroform,  or  bismuth  subiodid — had  best  be  substituted. 
This  liquid  paste  is  either  poured  into  the  prepared  bone  cavity  in  a 
liquid  state  or  is  forced  in  while  hot  enough  to  be  plastic. 

Beck's  paste  consists  of: 

Bismuth  subnitrate  (c.  p.),  30  parts. 
White  wax,  5  parts. 
Paraffin,  5  parts. 
Petrolatum,  60  parts. 

This  makes  a  semisolid  mass,  which  should  be  slightly  warmed  be- 
fore being  used. 

In  the  parts  of  the  body  where  the  cavity  is  accessible  and  can  be 
rendered  and  maintained  aseptic,  it  is  customary  to  scrape  out  all  gran- 
ulations down  to  healthy  bone  and  then  attempt  to  sterilize  the  cavity 
by  first  pouring  in  95  per  cent  carbolic  acid,  removing  the  excess 
with  alcohol.     The  cavity  is  then  filled  with  Mosetig's  bone  wax,  or 


402  SURGERY  OF  THE  MOUTH  AND  JAWS. 

decalcified  bone  chips,  and  the  soft  tissues  covering  the  cavity  are  then 
closed  without  drainage.  If  by  this  method  infection  has  been  re- 
moved, there  will  be  no  suppuration,  and  the  filling  is  eventually  ab- 
sorbed. In  chronic  suppurating  cavities  which  are  less  accessible,  many 
remarkable  results  have  been  obtained  by  simply  filling  them  with 
Beck's  bismuth  paste.  It  has  been  used  mostly  in  fistulae  running  to 
bone  cavities,  about  tuberculous  joints,  or  in  chronic  empyema.  One 
injection  will  sometimes  cure  a  sinus  that  has  persisted  for  years.  When 
used  in  quantity,  there  is  danger  of  bismuth  poisoning.  In  one  case 
reported  by  David  and  Kaufmann,  death,  with  necrosis  of  the  jaws,  re- 
sulted after  an  injection  of  6  ounces  of  the  paste. 

It  is  on  account  of  the  impossibility  of  maintaining  perfect  asepsis 
in  a  cavity  communicating  with  the  mouth  that  methods  requiring  this 
are  not  applicable  here.  When  a  cavity  is  cleansed  by  the  method  de- 
scribed above,  or  even  simply  curetted,  a  certain  amount  of  injured 
or  dead  tissue  will  remain,  which  furnishes  a  culture  medium  for  any 
remaining  bacteria.  In  the  mouth  dependence  must  be  placed  upon  the 
antiseptic  power  of  the  uninjured  cells  in  the  granulations,  but  the 
cavity  must  be  free  from  diseased  or  dead  bone  or  diseased  granula- 
tions. If  it  contains  any  of  these,  they  must  be  removed,  but  after 
doing  this,  it  is  better  to  treat  the  cavity  with  light  gauze  packings  until 
healthy  granulations  line  the  walls ;  then  it  may  be  filled  with  the  bone 
plombe.  It  is  hardly  necessary  to  state  that  bone  plombe  is  not  to  be 
used  when  the  cavity  is  the  seat  of  any  active  infection. 

If  the  cavity  communicates  with  the  mouth  by  a  very  narrow  open- 
ing or  fistula.  Beck's  paste  is  applicable;  for  it  is  improbable  that 
poisoning  will  result  from  the  few  cubic  centimeters  that  will  be 
required  to  fill  a  cavity  in  a  jaw,  and  it  is  impossible  to  dry  out  such  a 
cavity  before  inserting  the  plombe.  If  the  opening  is  free,  then  the 
wax  is  to  be  used,  since  the  paste  would  not  stay  in  place.  To  use  the 
wax,  the  cavity  must  be  dry.  It  may  be  made  so  by  gentle  gauze  pack- 
ing or  by  a  stream  of  hot  air,  but  the  granulations  must  not  be  injured. 
The  paste  is  forced  into  the  cavity  in  a  semiliquid  state,  from  a  syringe 
or  a  collapsible  metal  tube  which  has  a  tapering  nozzle  that  will  fit 
tightly  in  the  opening  of  the  cavity  or  sinus.  The  whole  cavity  must 
be  filled,  leaving  no  dead  space  in  which  fluids  can  collect  and  bacteria 
propagate.  The  bone  wax  is  put  into  the  cavity  in  a  plastic  condition, 
either  with  a  syringe  or  tube,  or  forced  in  with  a  wax  spoon  or  some 
metal  instrument.  By  using  the  proper  fittings  to  a  hypodermic 
syringe,  the  bone  plombe  can  be  forced  through  a  root  canal  into  an 
apical  bone  cavity.  In  working  with  bone  plombe  in  the  upper  jaw, 
it  must   be  remembered  that   the   material  might  be   forced   into   the 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  403 

maxillary  antrum  or  between  the  bone  wall  of  the  antrum  and  its 
mucous  lining.  The  quantity  of  the  material  entering  will  somewhat 
serve  as  a  guide.  Whether  filling  a  suppurating  antral  cavity  with 
Beck's  paste  is  good  treatment  is  another  question.  If  the  first  attempt 
to  close  a  cavity  with  bone  plombe  is  not  successful,  it  may  be  repeated. 
When  the  cavity  is  in  suitable  condition,  the  use  of  bone  plombe  has  the 
advantage  of  requiring  no  cutting  operation  and  involving  no  detention 
from  ordinary  pursuits.  It  has  the  disadvantage  of  an  uncertainty  of 
the  result. 

Obliteration  of  the  Cavity  with  Living  Tissue. — This  is  done  by 
removing  the  thinner  of  the  bone  walls  which  bound  the  cavity,  by  the 
use  of  biting  forceps  or  a  bur.  This  can  usually  be  done  through  the 
mouth,  but  sometimes  a  supplementary  incision  along  the  lower  border 
of  the  jaw  is  necessary.  After  the  cavity  is  cleansed  and  one  wall  re- 
moved, it  may  then  be  lightly  packed  with  gauze  for  a  few  days,  when 
no  further  treatment  than  a  mouth  wash  should  be  required.  We  be- 
lieve that  unless  there  is  some  contraindication,  this  is  better  surgery 
than  the  use  of  bone  plombe  (Fig.  350). 

ACUTE   ULCEROUS   GINGIVITIS. 

The  treatment  employed  by  Dr.  Gilmer  has  proved  so  satisfactory 
for  the  occasional  cases  presenting  in  practice  as  well  as  for  the 
large  number  of  cases  of  "trench  mouth"  treated  in  France  that  the 
following  quotation  from  his  pen  will  be  sufficient : 

"After  having  treated  a  few  cases  by  local  antiseptic  applications 
only,  and  finding  the  obstinacy  of  the  disease  to  such  treatment,  and 
knowing  how  sensitive  the  gums  are  to  mercury,  I  concluded  to  try 
its  effect  by  giving  small  doses  of  calomel  in  combination  with  the 
local  treatment,  with  the  most  happy  results.  The  home  treatment 
consists  of  taking  four  tablets  of  mercurous  chlorid,  1/20  grain  each, 
morning,  noon  and  night  (twelve  tablets  in  all),  followed  by  a  saline 
cathartic  on  rising.  The  gums  are  thoroughly  cleansed  before  break- 
fast by  a  swab  of  cotton  dipped  in  hydrogen  peroxid.  Every  two 
hours  during  the  day  the  mouth  is  flushed  with  a  warm  saturated 
solution  of  boric  acid,  to  which  is  added  one  drop  of  the  oil  of  cassia 
to  two  ounces  of  the  solution.  The  oft'ice  treatment  consists  in  a 
'thorough  cleansing  of  the  parts  in  the  afternoon  with  hydrogen  per- 
oxid, followed  by  the  application  of  compound  tincture  benzoin.  On 
the  third  day  under  this  treatment  a  marked  improvement  has  uni- 
formly been  observed,  and  in  a  few  days  more  the  gums  have  been 
fully  restored.  In  the  place  of  the  benzoin,  dilute  tincture  of  iodine 
may  be  substituted  with  good  results." 


404  SURGERY  OF  THE  MOUTH  AND  JAWS. 

GINGIVITIS   CAUSED  BY   DEPOSITS   OF  SALIVARY 

CALCULUS. 

The  treatment  for  the  inflammations  caused  by  these  deposits  is 
simple,  consisting  in  the  removal  of  the  deposits  and  the  douching 
of  the  soft  tissues  with  warm  saline  solution  two  or  three  times  a 
day  for  several  days  until  epithelium  has  replaced  the  granulations. 
Patients  should  be  instructed  in  the  means  of  preventing  the  recur- 
rence of  these  deposits  by  better  care. 

Black^  has  shown  that  the  deposits  are  so  soft  for  twelve  hours 
or  more  after  they  occur  that  they  may  be  readily  removed  with  the 
tooth  brush,  so  that  the  accumulation  may  be  entirely  prevented  by 
proper  brushing  twice   daily. 

GINGIVITIS  CAUSED  BY  DEPOSITS  OF  SERUMAL 
CALCULUS. 

As  this  form  of  deposit  always  occurs  on  the  enamel  under  the 
free  margin  of  the  gum,  it  may  go  undiscovered  until  serious  damage 
to  the  deeper  tissues  has  occurred.  If  the  case  has  not  progressed 
so  as  to  have  caused  the  detachment  of  the  peridental  membrane,  the 
careful  and  complete  removal  of  the  deposits,  followed  by  thorough 
irrigation  with  saline  solution  will  be  all  the  treatment  required.  If 
there  is  any  other  form  of  gingival  irritation,  the  quantity  of  serum 
exuded  is  increased  and  this  is  likely  to  result  in  a  corresponding 
increase  in  the  deposit  of  calculus. 

GINGIVITIS  DUE  TO  INJURIES. 

It  seems  hardly  necessary  to  call  attention  to  the  fact  that  all 
forms  of  irritation  of  the  gingivae  should  be  studied  to  ascertain 
the  cause  and  that  the  cause  should  be  removed.  The  gingivae  will 
withstand  much  abuse ;  they  will  usually  recover  quickly  if  given 
the  opportunity.  In  view  of  the  disastrous  results  to  the  peridental 
membrane  when  the  gingivae  do  break  down,  it  is  important  that 
every  slight  area  of  inflammation  be  recognized  as  the  possible  fore- 
runner of  a  suppurative  pericementitis,  with  its  systemic  danger. 
This  recognition  will  do  much  to  stimulate  action  for  prevention.  The 
causes  are  usually  apparently  trifling — a  rough  margin  of  a  filling,  a 
space  between  the  teeth  where  food  lodges  at  each  meal,  a  crown 
margin  which  impinges  on  the  gum,  etc.  The  treatment  consists  of 
the  correction  of  these  conditions. 


IG.  V.  Black  :      Special  Dental  Pathology,  110. 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  405 

CHRONIC  SUPPURATIVE   PERICEMENTITIS. 

More  teeth'  are  lost  today  from  the  formation  of  pus  pockets  along 
the  sides  of  the  roots  than  from  dental  caries.  This  fact,  together 
with  the  well  recognized  secondary  systemic  effects,  and  the  intrac- 
tability of  these  cases  to  treatment,  makes  it  imperative  that  the  best 
means  of  prevention  be  employed.     Since  a  gingivitis  always  precedes 


Fig.  351.  Plaster  model  of  case  in  whicli  the  tissue  overlying  a  pocket  on  the 
buccal  side  of  the  mesial  root  of  a  lower  first  molar  was  cut  away  to  reduce  the  depth  of 
the  pocket  and  facilitate  the  cleaning. — G.   V.  Black. 


Fig.  352.  A  case  in  which  the  distal  root  of  a  lower  first  molar  was  amputated  on 
account  of  disease  of  the  peridental  membrane.  The  distal  half  of  the  crown  of  the  tooth 
was  also  cut  away,  and  a  gold  crown  was  made  to  restore  the  full  occlusal  surface. — 
G.  V.  Black. 

the  pericementitis,  it  is  clear  that  more  attention  to  the  inflammation 
of  the  gingivae  by  both  patient  and  dentist  is  greatly  to  be  desired. 

With  the  understanding  that  suppurative  detachments  of  the  peri- 
dental membrane  from  the  cementum  are  permanent,  we  may  lay 
down  rather  definite  rules  for  treatment.  We  have  a  condition  pre- 
senting a   pocket   along  the   side   of  a   tooth's   root,   which   makes   a 


406  SURGERY  OF  THE  MOUTH  AND  JAWS. 

convenient  incubator  for  the  organisms  of  the  mouth.  Our  first 
thought  is  that  infection  would  not  occur  if  the  pocket  could  be  kept 
clean.  Two  plans  are  proposed,  either  or  both  of  which  may  be  used 
in  a  given  case.  First  the  patient  may  be  given  a  syringe  of  convenient 
form  and  taught  to  irrigate  the  pockets  twice  daily  as  a  part  of  his 
mouth  hygiene  routine.  Second,  if  the  conditions  in  the  particular 
case  indicate  that  such  a  plan  will  not  succeed,  then  the  overlying 
detached  soft  tissue  may  be  removed  with  the  knife  or  cautery,  after 
novocain  has  been  injected  (Figs.  351  and  352).  Epithelium  will 
quickly  cover  the  raw  surfaces.  By  this  plan  the  pockets  are  at  once 
eliminated,  the  granulating  connective  tissue  is  done  away  with,  and 
the  systemic  danger  is  removed.  As  the  detachment  from  the  root 
is  usually  deeper  than  the  destruction  of  the  overlying  bone,  it  is 
often  necessary  to  trim  off  the  edge  of  the  bone,  in  order  to  remove 
the  soft  tissue  to  the  full  depth  of  the  pocket.  This  operation  may 
be  for  the  elimination  of  a  pocket  on  a  single  tooth,  or  it  may  consist 


Pig.  353.  Sketcli  illustrating  operation  for  elimination  of  pus  pockets  about  a 
number  of  teeth,  a,  margin  of  inflamed  gum  tissue  ;  ti,  depth  of  detachment  of  peridental 
membrane  from  root  :  c,  line  of  incision  to  lay  bare  portion  of  roots.  A  similar  incision 
is  made  on  the  lingual  side  and  the  septi  of  soft  tissue  between  the  teeth  are  also  removed. 

of  the  removal  of  detached  tissue  about  a  considerable  number  of 
teeth  (Fig.  353).  The  operation  is  not  essentially  different  from 
that  performed  by  Riggs  fifty  years  ago.  In  some  cases,  the  cutting 
away  of  the  gum  is  contraindicated  for  cosmetic  reasons.  In  all 
cases,  it  is  important  that  the  roots  of  the  teeth  be  free  from  deposits. 
Teeth  which  have  lost  so  much  of  their  membrane  that  they  are 
loose  should  be  extracted ;  or  if  the  pockets  are  so  deep  that  it  is 
impractical  to  remove  the  overlying  tissue,  or  to  clean  them  effectually 
with  the  syringe,  the  teeth  should  be  extracted.  Their  value  for 
mastication  must  often  be  weighed  against  the  systemic  danger  in  their 
retention.  Many  patients  have  been  observed,  who,  having  pus  pockets 
of  varying  depths  about  their  teeth,  have  gone  about  their  daily  duties 
for  many  years,  with  sallow  complexions,  inactive  physically,  lacking 
initiative,  never  very  sick  Init  always  deficient  in  vigor,  and  who 
have  finally  consented  to  the  removal  of  the  teeth  with  the  surprising 
result  that  they  have  almost  immediately  come  to  take  new  interest 
in  life,  to  be  able  to  do  more  and  to  enjoy  it,  to  have  a  better  color, 


TREATMENT  OF  INFECTIONS  OF  THE  TEETH.  407 

a  sharper  eye,  and  a  quicker  step,  to  have  the  feehng  that  they  are 
really  well  and  vigorous. 

There  is  an  impression  made  by  these  cases  which  convinces  one 
that  it  is  quite  as  important  to  keep  mouths  free  from  infection  as 
other  parts — that  there  is  a  wonderful  field  of  preventive  medicine 
open  to  the  dentist. 

SPECIFIC  INFECTIONS. 

Actinomycosis. — If  a  necrosis  is  due  to  actinomycosis,  after 
treating  the  local  infection,  the  patient  is  to  be  given  large  doses  of  po- 
tassium iodid  or  copper  sulphate  for  an  extended  period.  Potassium 
iodid  is  the  older  treatment,  but  based  upon  observations  made  at  the 
experimental  agricultural  station  in  Wisconsin,  Bevan  first  treated  this 
disease  in  man  with  copper  sulphate  and  reports  very  good  results.^ 
After  removing  the  granulations,  the  cavity  might  be  packed  with  gauze, 
wet  with  weak  copper  sulphate  solution. 

Tuberculosis  of  the  Jaw-Bones. — Tuberculosis  of  the  upper  and 
of  the  lower  jaws  run  radically  different  clinical  courses.  The  viru- 
lency  of  the  infection  increases  in  proportion  to  its  distance  from  the 
orbit.  Metastatic  infection  of  the  body  of  the  maxilla  runs  the  same 
mild  course  as  does  a  tuberculous  infection  in  other  bones.  Infections 
of  the  upper  alveolar  process  and  palate  are  more  severe,  while  in 
tuberculosis  of  the  body  of  the  lower  jaw  the  disease  is  aggressive,  and 
unless  checked  by  very  radical  treatment,  usually  terminates  fatally 
within  two  or  three  years. 

The  treatment  of  infections  of  the  maxilla  is  the  same  as  that  of 
other  bones.  The  cavity  is  curetted  and  obliterated,  with  either  living 
tissue  or  some  bone  plombe.  Infection  of  the  palate  or  alveolar  process 
usually  takes  place  within  the  mouth.  It  will  usually  yield  to  curetting 
and  repeated  applications  of  lactic  acid. 

In  the  lower  jaw  infection  from  the  mouth  follows  a  somewhat 
similar  course  as  infection  of  the  upper  alveolar  process  and  palate,  but 
is  more  malignant.  Unless  due  to  an  extension  from  a  tuberculous  ulcer 
of  the  tongue,  it  is,  however,  less  malignant  than  a  metastatic  infection 
of  the  body  of  the  lower  jaw,  which  latter  usually  occurs  somewhere 
along  the  lower  border.  In  metastatic  infection  of  the  mandible,  there 
may  be  a  hard  swelling,  usually  followed  by  persistent  trismus,  but  with 
little  pai^  and  few  constitutional  symptoms.  Later  there  will  be  soften- 
ing and  fistula,  with  caries  and  necrosis  of  the  bone.  There  will  be 
early  infection  of  the  lymph  nodes  and  later  of  the  other  soft  tissues  of 
the  neck  and  of  the  bones  of  the  base  of  the  skull.  The  disease  usually 
ends  fatally  in  a  very  few  years. 


2For  dosage  and  toxic  symptoms  of  potassium  iodid  and  copper  sulphate  see  a  text- 
book on  materia  medica. 


408  SURGERY  OF  THE  MOUTH  AND  JAWS. 

In  the  early  stages  only  a  microscopical  examination  and  possibly 
the  injection  of  a  guinea  pig  will  make  the  diagnosis  certain.  In  the 
later  stages  the  diagnosis  is  less  difficult.  The  early  enlargement  of 
the  lymph  nodes  should  help  to  distinguish  it  from  actinomycosis,  which 
rarely  causes  lymphatic  infection.  The  discharge  from  an  actinomycotic 
fistula  usually  shows  some  form  of  fungi,  while  the  discharge  from  a 
tuberculous  lesion  will,  when  properly  treated,  show  the  presence  of  the 
tubercle  bacilli.  If  Much's  contention  is  correct,  viz.,  that  the  tubercle 
bacillus  is  one  of  the  mycoses,  then  the  two  diseases  are  related  both 
in  their  etiology  and  in  their  clinical  course.  In  its  earlier  stages,  it  is 
to  be  distinguished  from  sarcomata  only  by  a  microscopical  examination. 
Even  later  this  may  be  necessary. 

Carcinoma  of  the  lower  jaw  is  never  primary  and  is  due  usually  to 
extension  from  some  perfectly  evident  neighboring  focus.  Carcinoma 
may  arise  in  the  mucous  lining  of  the  antrum,  but  the  age  of  the  patient 
will  usually  give  a  clue  to  the  diagnosis — carcinoma  rarely  occurring 
before  forty  and  tuberculosis  rarely  after  thirty  years,  but  there  are 
exceptions  to  these  rules. 

The  treatment  of  tuberculous  infections  of  the  lower  jaw  should  be 
as  radical  as  of  carcinoma  or  tuberculosis  of  the  tongue.  If  seen  and 
diagnosed  early,  a  wide  local  excision  in  healthy  tissues,  with  or  without 
extirpation  of  the  lymphatic  nodes,  should  be  done.  The  operation 
upon  the  lymphatic  nodes  had  best  be  postponed  until  time  has  demon- 
strated the  probable  success  of  the  operation  on  the  primary  focus. 
For  indications  and  technique  of  treatment  of  tuberculous  adenitis,  see 
Chap.  XXXIX.  In  all  cases  the  usual  hygienic  treatment  should  be 
carried  out. 

Syphilis. — Syphilitic  lesions  are  to  receive  no  local  treatment, 
except  the  use  of  mildly  antiseptic  washes,  until  the  disease  is  well 
under  control.    Then,  and  then  only,  may  sequestra  be  removed. 


CHAPTER  XXVIII. 

SEPTIC  INFECTIONS  OF  THE  FLOOR  OF  THE  MOUTH 

AND  NECK. 

Septic  infections  of  the  neck  are  usually  secondary  to  some  infec- 
tion in  the  mouth,  nose,  or  pharynx,  and  in  many  of  them  the  teeth  are 
the  portals  of  entry.  From  the  mouth  the  infection  travels  into  the 
neck  by  one  or  two  routes:  (1)  by  extension  along  the  cellular  tissue 
planes,  or  (2)  through  the  lymphatics.  In  many,  if  not  most  instances, 
the  infection  travels  by  a  combined  route,  but  usually  either  the  lymph 
nodes  or  the  tissue  planes  show  the  greater  involvement,  and  the  re- 
sulting inflammation  is  designated  accordingly  as  an  adenitis  or  cel- 
lulitis. 

ACUTE  ADENITIS. 

This  may  vary  from  the  enlargement  of  one  or  several  nodes,  which 
may  quickly  disappear  with  the  subsidence  of  the  primary  focus,  to  the 
rapid  swelling  of  a  number  of  nodes  in  one  or  several  groups,  accom- 
panied by  pain,  fever,  suppuration,  and  diffuse  periadenitis.  Naturally, 
one  of  the  upper  groups  of  nodes  is  most  commonly  affected.  The 
inflammatory  process  may  remain  limited  to  the  neighborhood  of  the 
involved  nodes,  or  may  be  widespread.  When  a  gland  capsule  rup- 
tures, the  pus  is  liberated  between  the  cellular  planes,  but  it  may  still 
remain  localized,  held  in  place  by  a  wall  of  granulations.  In  a  very 
acute  infection,  the  pus  may  form  more  rapidly  than  it  can  be  walled 
off,  in  which  case  it  will  travel  along  the  tissue  planes  under  the  deep 
cervical  fascia  and  may  enter  the  mediastinum  or  the  axilla.  A  local- 
ized abscess  may,  if  neglected,  rupture  spontaneously  through  the  skin 
or  travel  along  the  tissue  spaces  and  cause  death  before  the  pus  can 
reach  the  surface.  For  this  reason,  the  early  drainage  of  suppurative 
adenitis  in  the  neck  is  very  important.  Owing  to  the  number  of  pro- 
tecting lymph  nodes  in  the  neck,  general  infection  through  the  lym- 
phatics is  not  common.  After  proper  drainage,  if  not  too  long  delayed, 
recovery  usually  takes  place.  In  the  non-suppurative  forms  resolution 
may  be  long  delayed,  and  a  chronic  hyperplasia  of  the  nodes  may  result. 

ACUTE  CELLULITIS. 

The  most  common  instance  of  this  is  the  swelling  of  the  cheek  or 
floor  of  the  mouth  which  usually  accompanies  an  "ulcerated  tooth." 

409 


410  SURGERY  OF  THE  MOUTH  AND  JAWS. 

This  usually  subsides  spontaneously,  but  it  may  terminate  in  an  abscess 
contiguous  to  the  mouth.  In  the  neck  it  is  not  so  common  as  adenitis, 
but  some  local  periadenitis  always  accompanies  a  suppurative  adenitis. 

Ludwig's  Angina. — In  one  form,  the  infection  of  the  cellular 
planes  is  so  rapid  or  so  extensive  as  to  overshadow  the  lymphatic 
involvement.  This  presents  such  typical  clinical  characteristics  that  it 
is  called  Ludwig's  angina,  after  the  man  who  first  described  it.  This  is 
an  acute  spreading  infiltration  of  the  soft  tissues,  starting  in  the  floor 
of  the  mouth  and  submaxillary  region,  which  binds  all  the  structures 
into  a  hard,  board-like  mass.  The  swelling  is  attached  to  the  jaw-bone 
on  one  or  both  sides  and  presses  the  tongue  upward  and  backward  in 
the  pharynx.  The  roof  and  side  walls  of  the  mouth  are  unyielding, 
and  any  hard  swelling  in  the  floor  must  crowd  the  tongue  backward. 
Though  not  very  common,  Ludwig's  angina  is  of  great  interest,  because 
in  the  past  it  has  been  credited  with  a  mortality  of  about  40  per  cent. 

Its  existence  as  a  definite  clinical  entity  has  been  the  subject  of 
considerable  discussion.  We  have  seen  a  sufficient  number  of  cases 
to  conclude  that  it  is  as  definite  in  its  pathology  and  clinical  signs  as 
pneumonia  or  peritonitis,  either  of  which  may  be  caused  by  any  one 
of  a  number  of  infectious  agents.  The  trouble  often  starts  in  a  sub- 
acute swelling  which  may  remain  indolent  for  some  days  or  weeks,  but 
when  it  becomes  active,  the  swelling  spreads  rapidly  until  the  whole 
floor  of  the  mouth  and  front  of  the  neck  may  be  involved.  At  first  the 
skin  is  not  red  but  pale  and  immovable  on  the  subjacent  swelling, 
and  does  not  pit  on  pressure.  There  is  little  constitutional  disturbance, 
and  though  the  patient  will  usually  hold  the  mouth  slightly  open  and 
may  feel  more  comfortable  sitting  up,  the  respiratory  impediment  may 
go  almost  unnoticed.  Within  the  mouth  the  induration  may  be  felt  in 
the  floor  on  one  or  both  sides,  and  the  submucosa  may  be  so  edematous 
as  to  rise  above  the  level  of  the  teeth  in  a  gray  roll.  In  this  stage 
resolution  may  take  place  spontaneously,  but  more  commonly,  if  un- 
treated symptoms  of  grave  sepsis  develop  and  the  patient  survives  long 
enough,  there  will  be  discoloration  of  the  skin  with  diffuse  suppuration, 
or  partial  gangrene  of  the  deeper  tissues.  Pneumonia  is  not  an  in- 
frequent complication,  and  if  the  swelling  extends  back  into  the  pharynx, 
there  may  be  edema  of  the  glottis.  Death  in  from  7  to  20  days  is  a 
frequent  sequel  of  the  untreated  cases.  It  has  been  our  observation 
that  the  most  frequent  starting-point  of  the  infection  of  the  cellular 
tissue  has  been  a  suppurating  submaxillary  lymph  node  or  a  collection 
of  pus  in  the  floor  of  the  mouth.  However,  in  a  scries  of  typical  and 
atypical  cases  represented  before  the  St.  Louis  Surgical  Club,  February, 
1909,  we  reported  one  in  which  the  infection  started  in  an  upper  tooth, 
first  involving  the  tissues  of  one  side  of  the  head  and  face  before  reach- 


SEPTIC  INFECTIONS  OF  THE  MOUTH.  411 

ing  the  submaxillary  region.  In  another  the  infection  started  from  a 
sarcomatous  ulcer  of  the  lower  jaw,  while  in  a  thud  it  started  in  an 
abscess  under  the  thyrohyoid  membrane.  In  all  of  these  there  was  the 
board-like  swelling  of  the  floor  of  the  mouth  and  grave  sepsis  with 
respiratory  impediment.  It  is  difficult  to  obtain  pure  cultures  from 
abscesses  of  the  mouth,  but  there  is  a  pretty  general  opinion  that  this 
form  of  infection  is  usually  due  to  streptococcus.  From  the  freshly 
cut  tissues  in  some  cases  we  have  obtained  a  streptococcus  in  pure  cul- 
ture— less  frequently  Staphylococcus  aureus.  It  has  been  noticed  that 
the  disease  may  at  times  be  mildly  epidemic. 

CHRONIC  ADENITIS. 

This  is  usually  due  to  the  persistence  of  some  focus  within  the 
mouth  or  pharynx,  but  at  times  it  would  appear  as  if  the  infection  re- 
mained semiactive  in  the  nodes  themselves.  Usually,  after  the  sub- 
sidence of  an  acute  infection,  the  adenitis  disappears,  but  it  may  take 
on  a  chronic  form  in  which  the  nodes  remain  enlarged  or  may  even 
continue  to  increase  in  size.  This  may  occur  in  one  or  several  groups. 
On  section  such  enlarged  nodes  will  usually  show  a  simple  hyperplasia ; 
and  occasionally  an  abscess  may  develop.  Septic  infection  of  the 
lymphatic  nodes  sometimes  seems  to  be  the  predisposing  factor  of  a 
tuberculous  adenitis,  and  we  have  seen  endothelioma  and  Hodgkin's 
disease  start  in  cervical  lymph  nodes  that  were  infected  from  carious 
teeth.  In  both  instances  the  nodes  were  examined  microscopically  by 
Dr.  Downey  Harris  while  in  the  inflamed  stage,  when  neither  endo- 
thelioma nor  Hodgkin's  disease  could  be  demonstrated. 

CHRONIC  CELLULITIS  (HOLZPHLEGMON). 

This  is  an  indolent  hard  infiltration  of  the  cellular  tissue  that  may 
be  sharply  limited  and  very  resistant  to  treatment,  often  lasting  for 
months.  Unlike  Ludwig's  angina,  it  is  not  confined  to  the  floor  of 
the  mouth  and  front  of  the  neck,  but  more  often  attacks  the  lateral 
aspect  of  the  neck.  It  develops  slowly  and  causes  few  or  no  consti- 
tutional symptoms  and  little  or  no  suppuration.  Fichter  reports  five 
cases  in  which  he  found  numerous  pus  organisms.  We  have  found  the 
streptococcus  and  Staphylococcus  aureus  in  pure  culture  in  different 
cases.  After  persisting  for  a  period  of  time,  the  induration  subsides, 
leaving  little  or  no  trace  of  its  former  presence. 

TREATMENT  OF  ACUTE  ADENITIS. 

This  will  depend  somewhat  upon  the  virulency  and  extent  of  the 
infection.  In  simple  enlargement  the  nodes  themselves  need  no  special 
attention,  even  though  they  be  rather  tender,  but  ice  may  be  applied  to 


412  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  neck ;  and  the  intraoral  focns,  or  angina,  should  be  treated.  When 
from  the  general  .symptoms  and  the  periadenitis,  with  increased  local 
tenderness,  it  is  believed  that  suppuration  has  occurred  in  one  or  several 
nodes,  these  should  be  opened  and  drained ;  and  at  the  same  time  a 
culture  should  be  made.  In  case  prompt  recovery  does  not  occur,  an 
autogenous  vaccine  can  then  be  made.  If  the  pus  is  superficial  and 
definite  fluctuation  can  be  detected,  the  drainage  incision  may  be  made 
directly  into  the  abscess,  or,  after  incising  the  skin,  the  fascia  may  be 
penetrated  with  a  round-nosed  artery  forceps,  after  the  plan  of  Hilton. 
The  opening  should  be  large  enough  to  admit  the  gloved  finger.  A 
counter  opening  is  made  at  the  most  dependent  point,  and  a  strip  of 
rubber  dam  is  drawn  through  these  two  openings,  to  be  left  in  place 
until  all  active  secretion  ceases.  The  skin  incisions  should  always  be 
made  transverse  to  the  long  axis  of  the  neck,  when  they  will  leave 
almost  no  scar. 

Very  often,  in  the  more  virulent  infections,  there  will  be  clinical 
evidence  of  suppuration,  while  the  pus  is  still  too  deep  or  the  quantity 
is  too  small  to  be  detected  by  the  palpating  finger.  Small  foci  of 
suppuration  may  be  present  in  a  number  of  nodes  buried  beneath  a 
thick  layer  of  inflamed  periglandular  tissue.  It  is  safe  in  few  parts 
of  the  neck  to  make  deep  stab  incisions  for  drainage.  When  pus  is 
suspected  to  be  deep  in  the  nodes,  it  is  a  better  and  more  expeditious 
procedure  to  expose  the  mass  of  inflamed  glands,  which  may  be  done 
through  Kocher's  transverse  incision  or  by  an  incision  running  along 
the  border  of  the  sternomastoid  muscle.  The  former  is  a  little  more 
difficult,  but  gives  a  much  less  noticeable  scar.  Most  of  the  deep  cer- 
vical nodes  lie  under  the  sternomastoid,  and  this  muscle  will  have  to  be 
retracted  to  expose  them.  Large,  softened  nodes  may  be  punctured 
with  a  round-nosed  artery  forceps  or,  very  exceptionally,  shelled  out, 
and  dependent  drainage  made  with  a  rubber  dam.  The  wound  of  ap- 
proach may  be  packed  or  sutured  at  the  operator's  discretion,  but  the 
whole  operation  should  be  done  quickly  and  thoroughly.  While  the 
very  early  liberation  of  pus  is  conducive  to  both  the  safety  and  the 
comfort  of  the  patient,  still  prolonged  or  repeated  operations  for  sepsis 
are  always  to  be  deplored.  If,  at  the  time  of  the  operation,  it  is  sus- 
pected that  pus  has  found  its  way  into  the  mediastina,  then  the  patient 
should  be  placed  in  a  bed,  the  foot  of  which  is  very  much  elevated  so 
that  the  drain  in  the  neck  will  be  at  the  most  dependent  point. 

TREATMENT  OF  ACUTE  CELLULITIS. 

The  safest  treatment  of  all  septic  indurations  of  the  floor  of  the 
mouth  is  early  free  incision.  Any  particular  induration  might  subside 
without  incision,  but  one  cannot  tell  which  of  them  is  the  early  stage 


SEPTIC  INFECTIONS  OF  THE  MOUTH. 


4ir5 


of  virulent  infection.  If  the  induration  is  entirely  above  the  mylohyoid 
muscle,  the  incision  may  be  made  within  the  mouth.  If  it  is  around  a 
stone,  this  may  be  removed  at  the  same  time,  but  if  it  arises  in  con- 
nection with  an  infected  tooth,  it  is  not  always  safe  to  draw  the  latter 
until  the  inflammation  has  subsided.  For  a  deep,  extensive  induration 
that  can  be  felt  from  below  the  jaw,  the  incision  is  usually  made  best 
from  the  outside.  We  do  not  mean  by  this  that  an  external  wound  is  to 
be  made  for  every  infection  about  the  lower  jaw.  We  do  believe  that 
deep,  hard,  septic  indurations  of  the  floor  can  be  better  drained  and 
more  safely  approached  from  the  outside  than  from  within  the  mouth, 
and  that,  if  the  incision  is  made  under  the  body  of  the  jaw,  it  will  not 
cause  a  noticeable  scar.     The  mylohyoid  muscle  is  divided  with  forceps 


I^Y  - Digastric  muscle. 

"  Mylohyoid  muscle. 

m  »\.   Hyoid  bone. 


Submaxillary  salivary  gland. 


Fig.  354.  Location  of  the  submental  and  submaxillary  lymph  nodes.  Lines  of  in^ 
cisions  for  dividing  the  digastric  and  mylohyoid  muscles  in  an  Indurating  cellulitis  of 
the  floor  of  the  mouth. 


in  the  direction  of  its  fibers.  In  Ludwig's  angina,  as  pointed  out  by 
Thomas,  there  is  the  double  indication  of  free  drainage  of  all  of  the 
cellular  planes  and  of  freeing  the  mouth  from  the  upward  pressure  in 
the  floor.  This  we  believe  can  be  best  accomplished  by  the  incisions 
shown  in  Fig.  354. 

The  skin  is  infiltrated  with  a  ^  per  cent  solution  of  novocain,  and 
an  incision  is  carried  from  the  tip  of  the  chin  to  the  hyoid  bone  and 
from  the  latter  point  outward  under  the  angle  of  the  jaw  as  far  as  the 
outer  margin  of  the  induration.  The  median  incision  and  the  median 
part  of  the  lateral  incision  are  carried  boldly  through  the  deep  fascia, 
but  as  part  of  the  lateral  incision  might  pass  over  the  fascial  vein 
and  carotid  arteries,  it  is  made  with  more  precision.  The  tissues  cut 
as  if  they  were  frozen  and  bleed  but  little.     A  flap  is  drawn  upward 


414 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


exposing  the  digastric  muscle  and  the  lower  part  of  the  submaxillary 
gland.  Here  a  suppurating  lymph  node  is  often  found.  If  there  is  any 
induration  in  the  floor  of  the  mouth  above  the  mylohyoid,  this  muscle 
and  the  anterior  belly  of  the  digastric  are  cut  through  on  the  lines 
shown  in  Fig.  oo-i:,  when  search  can  be  made  for  pus.  In  the  floor  it  is 
usually  found  along  the  inner  surface  of  the  body  of  the  jaw,  but  in 
one  case  we  found  it  deep  in  the  substance  of  the  tongue.  If  the  in- 
duration has  crossed  the  midline,  the  same  incisions  are  made  on  the 
other  side,  but  in  no  instance  are  the  geniohyoid  muscles  to  be  cut. 
These  incisions  allow  the  indurated  sections  to  roll  outward,  which 
frees  the  floor  of  the  mouth  (Figs.  35-5  and  356).    In  every  instance  but 


Fig.   355.      Showing  how  the  tissues  open  up  after  making  the  incision  described  for 
Ludwig's  angina. 

one,  when  done  early,  the  operation  in  our  liands  has  been  followed  by 
early  recovery.  When  the  induration  subsides,  the  tissues  drop  back 
into  place,  and  but  a  linear  scar  remains  (Fig.  3-37).  If  the  induration 
has  extended  down  the  neck  below  the  hyoid  bone,  then  a  vertical  in- 
cision is  made  in  the  midline,  which  allows  two  more  triangular  flaps  to 
be  retracted.  In  the  latter  cases  careful  search  for  pus  should  be  made 
among  the  infrahyoid  muscles.  In  one  instance  already  mentioned,  pus 
was  found  beneath  the  thyrohyoid  ligament,  and  recovery  took  place. 
The  wounds  are  packed  with  gauze  and  are  never  sutured.  Extreme 
restlessness  may  result  from  sepsis,  but  it  is  often  caused  by  partial 
obstruction  to  respiration.  If  after  proper  incisions  in  the  floor  of  the 
mouth  restlessness   persists,  which  is  not  relieved  by  a  sedative  but  is 


SEPTIC  INFECTIONS  OF  THE  MOUTH. 


415 


partially  relieved  by  allowing  the  patient  to  sit  up,  then  tracheotomy 
is  to  be  considered,  and  if  one  can  be  satisfied  that  the  respiratory  im- 
pediment is  not  due  to  pneumonia,  the  tracheotomy  should  not  be 
delayed  too  long. 

These  patients  should  have  general  supporting  treatment  and  sleep. 

TREATMENT  OF  CHRONIC  ADENITIS. 

The  first  indication  is  a  search  for  some  septic  focus  that  can  be 
keeping  up  the  irritation  in  the  lymph  nodes ;  and  the  general  hygiene 
of  the  patient  is  to  receive  attention.  In  the  rare  instances  where  sin- 
gle groups  of  nodes  continue  to  enlarge  without  apparent  cause,  it  is 


Fig.  356.  Lateral  view  of  patient  recentlj'  operated  for  Ludwig's  angina,  further 
illustrating  how  the  tissues  open  up. 

often  well  to  dissect  these  out  en  masse.  All  pathological  enlargements 
are  to  be  regarded  with  suspicion.  If  the  enlargement  is  due  to  an 
encapsulated  septic  infection,  it  is  well  to  have  it  out,  but  it  is  not 
improbable  that  on  section  it  will  be  found  that  some  graver  change 
has  occurred — such  as  tuberculous  infection — or  even  that  the  growth 
is  due  to  an  actual  tumor  of  the  nodes.  Before  making  such  an  ex- 
cision, the  surgeon  must  satisfy  himself  that  the  enlargement  is  not 
simply  a  part  of  a  generalized  disease  of  the  lymphatics,  such  as  Hodg- 
kin's  disease,  and  is  not  secondary  to  some  other  focus. 

These  dissections  are  often  made  very  difficult  by  the  scarring  that 
has  occurred  in  the  periglandular  tissue.  After  the  removal  of  the  mass 
of  chronically  diseased  nodes,  the  wound  is  to  be  closed  with  proper 


416 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


drainage,  which  latter  is  to  remain  in  place  as  long  as  there  is  any  active 
secretion.     In  non-suppurating  cases  this  may  be  about  a  week. 

TREATMENT  OF  CHRONIC  CELLULITIS. 

This  has  been  found  to  be  remarkably  resistant  to  all  ordinary  forms 
of  treatment  and  seems  to  be  little  affected  by  drainage  incisions.  The 
usually  favorable  outcome  of  the  disease  hardly  warrants  extensive 
deforming  incisions,  and  the  latter  have,  apparently,  comparatively  little 
effect.  It  seems  to  us  that  the  most  promising  treatment  is  to  obtain 
an  autogenous  vaccine,  obtained  by  incision  and  culture,  and  after  pro- 


Fig.  357.  Patient  shown  in  the  preceding  figures,  eight  days  after  operation.  As 
soon  as  the  induration  subsides,  the  flaps  drop  back  in  their  normal  positions. 

tecting  the  patient  by  appropriate  doses,  to  encourage  the  circulation 
through  the  inflamed  area  by  cupping  (Bier's  hyperemia). 

PHLEGMONOUS  STOMATITIS. 

The  term  phlegmonous  may  be  applied  to  any  septic  infection  of  a 
severe  type,  although  the  area  involved  may  be  very  limited.  Phleg- 
monous stomatitis  may  affect  any  part  of  the  mucous  membrane  and 
subjacent  tissues.  It  is  usually  dependent  upon  some  local  injury  or 
ulceration  which  forms  the  portal  of  entrance  of  a  virulent  pus  infection. 
Sometimes  a  tender,  painful,  and  somewhat  sharply  outlined  induration 
will  appear  in  the  cheek,  without  apparent  cause,  and  upon  inspection 
the  mucous  surface  shows  no  cause.  In  a  number  of  cases,  by  passing 
a  lunar  caustic  stick  over  the  surface,  an  excoriated  patch  was  revealed 
by  the  white  chlorid  stain  that  resulted.     The  inflammation  rapidly  pro- 


SEt'TIC  INFECtiONS  OF  THE  MOUTH.  4lt 

gresses  to  the  stage  of  infiltration  or  suppuration,  with  sometimes  the 
formation  of  ^  fibrous  exudate  dinging  to  the  mucous  surface.  The 
infiltration  and  swelling  are  usually  somewhat  sharply  limited,  but  the 
remaining  mucous  membrane  shows  a  lesser  type  of  inflammation. 
There  is  considerable  pain  and  immobility  of  the  part  affected.  The 
tongue  may  be  so  enlarged  as  to  protrude  from  the  mouth,  while  the 
swelling  around  the  tonsil  may  almost  close  the  fauces.  If  a  deep 
suppuration  occurs,  especially  in  the  posterior  part  of  the  mouth,  there 
may  be  danger  of  asphyxia  or  septic  pneumonia,  and  any  septic  in- 
fection may  be  followed  by  general  sepsis.  There  may  be  no  apparent 
general  disturbance,  or  there  may  be  an  increased  temperature  and  pulse 
rate  with  other  evidences  of  intoxication. 

The  treatment  will  consist  in  the  early  use  of  a  cold  application,  ice 
in  the  mouth,  an  ice  bag  under  the  chin,  and  attention  to  the  bowels, 
digestion,  etc. 

If  there  is  a  superficial  abrasion  of  the  mucosa,  it  should  be  re- 
peatedly painted  with  a  2  per  cent  solution  of  silver  nitrate.  If  the  dis- 
ease has  progressed  to  the  stage  of  marked  induration,  hot  applications 
may  be  more  grateful.  All  painful,  deep  indurations  should  be  freely 
incised,  especially  any  points  of  increased  tenderness.  Such  incisions 
may  open  an  abscess,  or  the  resulting  drainage  prevent  its  formation. 
In  phlegmonous  inflammations  of  the  tongue  the  dorsum^  may  be  in- 
cised to  its  full  extent,  but  deep  incision  should  usually  be  made  near 
the  midline  to  avoid  the  chance  of  serious  hemorrhage.  (For  treat- 
ment of  peritonsillar  abscesses,  see  Chap.  XL.) 

The  patient  should  be  given  all  the  rest  and  comfort  possible,  and 
anodynes  may  be  of  service,  especially  aspirin  and  phenacetin,  if  the 
patient  is  in  good  condition  and  can  swallow  them — otherwise,  mor- 
phin  hypodermatically.  But  these  should  not  be  substituted  for  early 
incisions  of  painful  indurations.  Supporting  treatment  should  be  given 
where  indicated. 

ABSCESS  OF  THE  TONGUE. 
Abscess  of  the  tongue  is  extremely  rare,  and  more  often  occurs  in 
a  subacute  form  and  may  be  surrounded  by  considerable  induration. 
It  has  been  mistaken  for  gumma  or  a  tumor.  In  a  case  that  came  into 
our  service  in  the  City  Hospital,  an  elderly  man  had  a  hard  sAvelling 
in  the  under  surface  of  the  body  of  the  tongue  extending  into  the  floor 
of  the  mouth.  It  had  given  him  little  pain,  but  its  size  caused  incon- 
venience. It  was  exposed  from  below  the  chin  through  the  incision 
described  under  Ludwig's  angina,  and  though  a  considerable  quantity 
of  pus  was  liberated,  the  surrounding  wall  was  so  hard  and  so  sharply 
defined  that,  until  the  microscope  and  subsequent  behavior  proved  it 
to  be  inflammatory,  we  thought  it  was  a  broken-down  carcinoma. 


CHAPTER  XXIX. 

DISEASES   OF  THE  MAXILLARY   SINUS. 

The  maxillary  antrum  is  an  accessory  sinus  of  the  nose,  occupying 
the  body  of  the  maxilla.  At  birth  it  is  rudimentary  and  attains  full 
development  at  the  twelfth  year.  It  is  bounded  above  by  the  floor  of 
the  orbit,  internally  by  the  lateral  wall  of  the  nose,  anteriorly  and  ex- 
ternally by  the  anterior  and  lateral  walls  of  the  maxilla;  while  the 
floor  is  at  the  base  of  the  alveolar  process.  The  cavity  occasionally 
extends  into  the  hard  palate  for  variable  distances,  even  to  the  midline. 
It  is  lined  with  mucoperiosteum  and  ordinarily  communicates  with  the 
nose  by  an  aperture  high  up  in  its  inner  wall,  which  opens  into  the 
middle  meatus — sometimes  there  are  accessory  openings.  The  cavity 
normally  contains  air  and  is  lined  with  ciliated  epithelium  which  carries 
the  mucous  secretion  upward  and  outward  through  the  nasal  opening. 
The  cavity  is  sometimes  divided  by  incomplete  bony  septa.  The  apices 
of  the  roots  of  the  molar  and  second  bicuspid  teeth  are  in  close  relation 
with,  or  perforate,  the  floor.  In  some  cases  the  apices  rise  above  the 
floor,  covered  only  by  the  mucous  and  the  peridental  membranes.  Oc- 
casionally the  cuspid  and  first  bicuspid  have  a  similar  relationship. 

Although  the  antrum  may  be  the  seat  of  numerous  surgical  diseases, 
infection  followed  by  suppuration  due  primarily  to  pus  organisms,  or 
secondary  to  some  one  of  the  exanthemata  or  la  grippe,  is  so  common 
as  to  overshadow  in  importance  all  other  lesions  combined. 

ANTRAL  INFECTION. 

The  antrum  usually  becomes  infected  in  one  of  three  ways :  infec- 
tious material  enters,  or  an  infection  extends  from  the  nose,  through 
the  nasal  aperture;  or  infection  extends  to  the  submucous  tissue  or  bones 
of  the  floor  from  a  diseased  root  or  peridental  membrane.  Any  part 
of  the  wall  can  be  invaded  by  syphilis  or  tubercle  which  may  ul- 
cerate into  the  antrum,  but  this  is  of  much  rarer  occurrence.  It  will  be 
readily  understood  that  the  maxillary  antrum  is  a  common  field  which 
must  be  invaded  by  the  rhinologist,  the  general  surgeon,  and  the  dentist; 
but  at  least  its  mucous  lining  is  anatomically  and  physiologically  a  part 
of  the  nasal  fossa.  The  proper  treatment  of  all  chronic  suppurations  of 
the  cavity  consists  in  establishing  permanent  ventilation  from,  and 
drainage  into,  the  nose.  It  is  becoming  more  and  more  recognized 
that  the  rhinologist,  with  his   special   facilities   for  diagnosis  and   for 

418 


DISEASES  OF  THE  MAXILLARY  SINUS.  419 

doing  intranasal  operations,  is  the  one  most  fitted  for  the  treatment  of 
at  least  those  cases  which  are  secondary  to  a  nasal  infection  or  which 
require  intranasal  drainage.  If  the  infection  of  the  cavity  is  dependent 
on  an  intranasal  disease,  as  it  is  in  about  one  half  of  the  cases,  it  is  per- 
fectly evident  that  both  conditions  should  be  treated.  A  skilled  rhin- 
ologist  is  the  only  one  competent  to  treat  diseases  of  the  upper  nasal 
sinuses.  On  the  other  hand,  if  the  disease  is  an  extension  from  around 
a  tooth,  it  is  just  as  important  that  this  source  of  infection  be  eliminated. 
In  the  acute  or  subacute  stage  the  most  logical  procedure  in  cases 
infected  from  the  teeth  is  to  drain  both  the  cavity  and  the  diseased 
submucous  tissues  through  the  same  opening,  which  can  be  done  at  least 
as  well  by  the  dentist  or  the  general  surgeon  as  by  the  rhinologist. 

When  the  suppuration  becomes  chronic,  permanent  drainage  from 
a  dependent  point,  with  the  removal  of  hopelessly  diseased  tissue,  is 
the  only  treatment  which  has  been  found  to  give  permanent  relief. 
Attempts  to  establish  permanent  drainage  into  the  mouth  have  been 
comi'ion,  but  they  require  the  constant  use  of  a  drainage  tube  or  plug  to 
prevent  the  closure  of  the  opening.  They  are  being  discarded  for  the 
nasal  route,  as  more  nearly  approaching  the  natural  physiological  and 
anatomical  conditions.  An  inflamed  antrum  may  contain  serum  or 
seropurulent  fluid  of  an  acute  infection  or  may  contain  thick  pus.  With 
chronic  suppuration  there  may  be  partial  or  complete  destruction  of  the 
surface  epithelium  or  the  whole  mucous  membrane,  or  it  may  be  thick- 
ened and  infiltrated  with  fibrous  tissue.  It  may  be  covered  with 
granulations,  or  the  antrum  may  contain  polypi,  denuded  bone,  or 
mucous  cysts. 

Subjective  Symptoms. — As  in  any  acute  pus  infection,  there 
may  be  fever,  leucocytosis,  and  an  increased  percentage  of  polymor- 
phonuclear cells  in  the  blood.  These  symptoms  are  especially  likely  to 
occur  if  the  pus  is  confined  by  obstruction  of  the  natural  opening.  With 
confined  pus  the  most  characteristic  and  constant  subjective  symp- 
toms are  pain  and  tenderness.  The  pain  may  be  local,  or  occur  in  the 
guise  of  a  headache  or  a  referred  neuralgia.  This  is  to  be  distinguished 
from  the  headache  resulting  from  eyestrain  in  that  it  is  not  relieved 
by  resting  the  eyes.  Headache  is  a  symptom  common  to  suppuration 
of  any  of  the  sinuses,  as  is  an  irritation  neuralgia  of  the  face,  running 
down  the  neck  and  arm  and  to  the  back  of  the  head,  but  pain,  tender- 
ness, or  a  full  feeling  over  the  sinus  is  more  apt  to  indicate  a  local 
trouble. 

According  to  Ballenger,  giddiness  and  vertigo,  or  a  momentary  sense 
of  blurred  or  darkened  vision  and  imminent  fainting,  are  frequently 
present  in  sinus  disease,  and  these  symptoms  may  be  made  worse  or 
produced  by  stooping  over. 


420  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Objective  Symptoms. — These  are  both  intranasal  and  extra- 
nasal.  The  intranasal  symptoms  may  consist  of  an  irregular  discharge 
of  fluid  or  pus  coming  in  gushes,  or  the  presence  of  pus,  or  a  plug  of 
mucus  and  pus,  under  the  center  of  the  middle  turbinated  bone.  Sup- 
puration of  the  nasal  mucous  membrane  is  comparatively  rare,  and  local 
patches  of  pus  near  the  orifices  of  the  sinuses  are  an  almost  certain  sign 
of  sinus  suppuration. 

The  middle  and  posterior  ethmoidal  cells  and  the  sphenoidal  sinus 
have  their  openings  above  the  middle  turbinate  bone.  The  frontal, 
anterior,  ethmoidal,  and  maxillary  sinuses  discharge  pus  to  the  same 
point  under  the  middle  turbinate,  so  that  when  pus  is  seen  here,  other 
means  will  have  to  be  used  to  determine  its  exact  source.  The  applica- 
tion of  a  little  10  per  cent  cocain  solution  to  the  site  will  facilitate  the 
examination.  The  antrum  will  hold  approximately  5  to  30  cubic  centi- 
meters of  fluid.  A  gush  from  the  nose,  brought  on  by  having  the 
patient  bend  forward,  is  very  suggestive  of  fluid  coming  from  the 
antrum,  but  may  also  be  from  the  sphenoidal  sinus.  If  the  opening  in 
the  nose  is  closed,  there  will  be  no  intranasal  discharge,  but  there  may 
be  a  bulging  into  the  middle  meatus  due  to  pressure  over  the  mem- 
branous part  of  the  wall. 

In  an  old  suppuration  with  much  pressure,  there  may  be  a  bulging 
or  rupture  into  the  orbit  with  exophthalmos,  or  there  may  be  a  thinning 
or  bulging  of  the  anterior  antral  wall.  The  anterior  wall  being  the 
thickest,  this  latter  condition  is  rare.  The  pus  may  perforate  and  bur- 
row under  the  face  tissues  or  the  soft  tissues  covering  the  palate. 

Another  objective  change  due  to  fluid  in  the  antrum  is  in  the  trans- 
mission of  light  or  the  x-ray.  If  an  electric  light  is  placed  in  the 
mouth  when  the  patient  is  in  a  dark  room,  the  light  is  transmitted 
through  a  normal  antrum^  and  shows  on  the  front  of  the  cheek  and 
lower  lid.  It  shows  a  red  crescent  of  light  over  the  lower  lid  and 
causes  a  red  pupillary  reflex.  The  patient  also  has  a  sense  of  light 
when  the  eyes  are  closed,  which  latter  is  a  subjective  phenomenon. 
When  there  is  fluid  in  the  antrum,  there  is  a  lessening  of  the  red 
pupillary  reflex  and  of  the  crescent  of  light  over  the  lower  lid,  also  a 
lack  of  sensation  of  light.  The  light  over  the  cheek  may  be  misleading, 
as  one  antral  wall  may  be  thicker  than  the  other.  Fluid,  or  a  growth 
in  a  sinus,  will  obstruct  the  x-ray,  causing  a  shadow  and  also  a  blurred 
outline  of  the  sinus.  This  latter  test  is  only  of  value  in  the  hands  of 
a  very  competent  roentgenologist. 

The  diagnosis  may  be  confirmed  or  disproved  by  puncturing  the 
antrum,  under  local  anesthesia,  either  through  the  nasal  wall  under  the 
inferior  turbinate  bone  or  through  the  canine  fossa.  It  was  an  older 
custom  to  puncture  the  antrum  through  the  root  socket  of  a  second 


DISEASES  OF  THE  MAXILLARY  SINUS. 


421 


bicuspid  or  molar  tooth.  This  is  a  more  difficult  procedure  than 
puncturing  the  antrum  wall  through  the  canine  fossa,  and  should  never 
be  done  unless  at  the  site  of  a  hopelessly  diseased  tooth. 

Treatment  of  Acute  or  Subacute  Antral  Infections  o£  Dental 
Origin. — The  antrum  may  be  infected  directly  from  a  root  canal. 
More  often  the  infection  is  secondary  to  an  alveolar  abscess,  but  an 
abscess  of  the  upper  alveolus  does  not  necessarily  imply  an  antral  in- 
fection. In  many  specimens  we  have  examined  in  the  dissecting  room, 
the  condition  indicated  in  Fig.  349  was  found,  with  every  evidence  that 
it  had  persisted  for  some  time  without  perforating  or  infecting  the 
antral  mucous  membrane.  When  an  abscess  in  this  location  is  acute, 
it  may  be  difficult  to  exclude  an  antral  infection  without  perforating 
the  cavity.  This  can  often  be  done,  by  the  dentist,  through  the  root 
canal  of  a  suspected  tooth,  but  this  is  not,  as  a  rule,  satisfactory  for 
either  diagnosis  or  drainage.     If  the  tooth  is  to  be  removed,  the  socket 


Fig.    358. 


Fig.    359. 


Fig.   358.      Opening   of   the   antrum   v/ith    a   gimlet.      A   trephine   driven   by   a   dental 
engine  is  more  commonly  used  for  this  purpose. 

Fig.   359.      Self-retaining  rubber  dam  drain  that  will  not  become  lost  in  the  antrum. 


can  be  drilled  right  up  into  the  antrum,  which  will  drain  both  the  antral 
cavity  and  the  alveolar  abscess.  Whether  the  tooth  is  to  be  preserved 
or  not,  we  think  it  is  often  preferable  to  drill  into  the  antrum  just  above 
the  apices  of  the  roots.  This  opening  is  easier  for  the  general  sur- 
geon to  make,  and  the  drainage  canal  does  not  need  to  be  plugged  to 
prevent  food  particles  from'  being  forced  into  it.  The  operation  is 
done  as  follows : 

The  tissues  are  anesthetized  with  1  or  IJ^  cubic  centimeters  of  a 
3  per  cent  novocain  solution  with  a  little  adrenalin  chlorid — 1  Prinz 
tablet  dissolved  in  IV3  cubic  centimeters  of  water,  injected  to  the 
bone.  The  mucous  tissues  and  the  bone  are  drilled  at  the  same 
time  with  some  sort  of  a  hand  drill  or  with  the  electric  dental  engine, 
that  will  make  an  opening  5  millimeters  in  diameter.  The  point  of  the 
instrument  is  applied  to  the  mucous  surface  at  a  point  just  above  the 
prominence  of  the  gum  and  inserted  upward  and  inward  (Fig.  358). 


432  SURGERY  OF  THE  MOUTH  AND  JAWS. 

If  it  is  to  be  opened  above  the  second  bicuspid,  the  drill  is  pointed  up- 
ward, backward,  and  inward ;  while  for  the  cuspid  it  is  pointed  upward 
and  backward.  By  this  means  the  antrum  is  entered  through  the  upper 
part  of  the  alveolar  process.  We  have  used  an  ordinary  carpenter's 
gimlet  ever  since  we  first  used  one  in  an  emergency  case.  If  pus  is 
found  in  the  antrum  or  under  the  mucous  lining,  or  even  if  there  is 
the  slighest  suspicion  of  pus  being  present,  a  rubber  dam  or  tube 
drainage  is  to  be  left  in  place  (Fig.  359).  If  the  antrim  is  not  already 
infected,  in  the  presence  of  an  alveolar  abscess  the  pus  will  easily  find 
its  way  into  the  cavity,  and  if  there  is  not  free  drainage,  antral  infec- 
tion will  result.  The  cavity  should  be  irrigated  with  normal  saline 
solution,  or  dilute  alkaline  antiseptic  solution  (N.  F.),  once  or  twice 
a  day  until  all  signs  of  suppuration  have  disappeared,  with  the  possible 
exception  of  a  slight  amount  of  pus  in  the  drainage  tube.  The  alveolar 
abscess  should  be  treated  as  already  outlined  in  Chap.  XXVII.  In  an 
acute  infection  drainage  will  have  to  be  provided  for  a  week  or  two,  at 
least  until  the  alveolar  abscess  or  tooth  infection  has  been  attended  to. 
In  a  subacute  infection  the  discharge  may  persist  for  a  month  or  six 
weeks ;  but  a  discharge  from  the  cavity  persisting  longer  than  six  weeks, 
after  free  drainage  is  furnished,  should  be  considered  chronic,  and  per- 
manent drainage  is  indicated.  Before  this  is  undertaken,  it  should  be 
ascertained  whether  any  of  the  upper  nasal  sinuses  are  infected,  for 
pus  pouring  into  the  middle  meatus  may  constantly  reinfect  the  antrum 
if  the  natural  aperture  is  patent. 

Treatment  of  Chronic  Antral  Infections. — Operations  for  the 
relief  of  chronic  antral  suppuration  fall  into  two  general  classes :  those 
which  provide  permanent  intranasal  drainage,  which  may  be  called 
conservative ;  and  those  which  furnish  free  access  to  the  cavity  whereby 
diseased  tissue  may  be  removed  with  a  curette.  In  the  great  majority 
of  cases  permanent  relief  will  be  obtained  by  one  of  the  operations 
which  are  collectively  styled  the  Mikulicz,  which  consist  in  establishing 
a  large  permanent  opening  between  the  antrum  and  the  nose  through 
the  inferior  meatus.  Schaeffer  was  the  first  to  describe  the  method  of 
puncturing  the  antrum  through  the  lateral  wall  of  the  middle  meatus. 
Various  techniques  have  been  devised,  most  of  them  including  the  re- 
moval of  part  of  the  inferior  turbinate  bone.  The  most  eflfective  of 
these  is  the  operation'  described  by  Sluder.  It  provides  the  largest 
opening,  and  at  the  same  time  is  the  most  conservative,  for  it  pre- 
serves the  inferior  turbinate  bone  intact.  While  perfect  access  for 
curetting  the  antrum  cannot  be  obtained  by  the  Mikulicz  operation,  it 
is  a  question  whether  curetting  is  often  necessary.  Free  permanent 
drainage  being  provided,  there  rarely  remains  anything  to  keep  up  the 
irritation ;  dead  bone  will  be  thrown  oflf,  polypi,  which  are  inflammatory 


DISEASES  OF  THE  MAXILLARY  SINUS.  423 

growths,  will  at  least  cease  to  grow,  and  the  mucous  membrane  will 
have  the  best  chance  to  regenerate.  Discretion  is  to  be  exercised  in 
curetting  the  interior  of  the  antrum.  Polypi,  dead  bone,  and  heavy, 
coarse  granulations  may  be  removed,  but  the  small  granulations  are  to 
be  left  alone  in  the  hope  that  the  deeper  epithelium,  lining  the  mucous 
follicles,  may  eventually  cause  a  reepithelization  of  the  surface.  If  the 
mucous  membrane  is  entirely  destroyed  or  removed,  then,  unless  a  flap 
is  transplanted  from  the  nose,  the  cavity  can  be  lined  only  with  scar 
tissue. 

KiJSTER  Operation. — The  older  radical  operation  of  entering  the 
antrum  through  a  large  opening  made  in  the  canine  fossa  and,  after 
removing  granulations,  polypi,  or  dead  bone,  packing  or  treating  the 
cavity  for  a  period  will  be  successful  in  a  number  of  cases,  but  not  in 
all ;  for  the  opening  will  eventually  close,  and  the  suppuration  is  liable 
to  recur.  It  is  sometimes  called  the  Kiister  operation  and  is  performed 
as  follows : 

An  incision  is  made  down  to  the  bone  over  the  canine  fossa  in  the 
upper  fornix.  The  soft  tissues,  including  the  periosteum,  are  raised 
with  an  elevator,  and  the  anterior  wall  is  removed  with  a  perforator  and 
biting  forceps  until  the  opening  is  1^  centimeters  in  diameter.  Then 
a  light  is  thrown  into  the  cavity ;  and  all  diseased  tissue  is  removed,  and 
any  septa  present  are  broken  down.  The  cavity  is  loosely  packed  with 
gauze  saturated  with  compound  tincture  of  benzoin,  the  end  of  the 
gauze  protruding  into  the  fornix.  Subsequently  the  cavity  is  irrigated 
daily,  and  when  suppuration  ceases,  the  wound  is  allowed  to  close. 

Caldwell-L'UC  Operation. — The  Mikulicz  operation  has  been 
combined  with  the  Kiister  under  the  name  of  the  Caldwell-Luc  opera- 
tion, which  is  really  a  radical  procedure  giving  free  access  to  the  cavity 
and  also  providing  permanent  drainage.  In  this  operation  the  diseased 
tissue  is  removed,  and  the  mucous  lining  of  the  inferior  meatus  is 
turned  into  the  floor  of  the  antrum.  Then  the  opening  through  the 
canine  fossa  is  immicdiately  sutured,  and  all  further  treatments  are 
carried  on  through  the  nasal  opening.  It  is  difficult  even  by  this 
means  to  remove  granulations  or  diseased  bone  from  the  anterior  in- 
ferior angle  of  the  cavity,  and  these  may  cause  the  infection  to  persist. 

Di^NKER  Operation. — The  Denker  operation  overcomes  this  diffi- 
culty, gives  free  access  to  the  sinus,  provides  permanent  intranasal 
drainage,  and  for  its  performance  does  not  require  the  special  technical 
skill  which  is  needed  for  an  intranasal  operation  done  through  the 
anterior  nares.  It  should,  therefore,  appeal  to  the  general  surgeon  as 
most  appropriate  for  all  cases  of  chronic  antral  suppuration  requiring 
radical  treatment.    The  technique  of  the  operation  is  as  follows : 

The  operation  is  best  done  under  a  general  anesthetic.     The  patient 


424 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


is  placed  in  the  Rose  position  with  the  head  hanging  over  the  end  of 
the  table,  but  supported  by  an  assistant.  Postnasal  tamponage  may  be 
used,  but  if  the  head  hangs  well  downward,  this  is  not  necessary.  The 
labiogingival  incision  is  made  as  in  the  Kiister  operation,  but  extends 
to  the  median  line.  The  soft  tissues,  including  the  periosteum,  are 
elevated,  the  antrum  is  opened  through  the  canine  fossa,  and  the  lower 
part  of  the  bridge  of  bone,  between  the  antrum  and  the  opening  of  the 
nose,  is  removed.  This  piece  of  bone  is  thick  and  will  require  strong 
biting  forceps.  By  this  the  anterior  inferior  angle  is  opened,  and  the 
whole  cavity  is  accessible  to  the  curette.  Bony  partitions  should  be  re- 
moved along  with  such  pathological  tissue  as  may  seem  expedient 
(Fig.  360).  If  there  is  to  be  a  mucous  flap  turned  from  the  nose  to 
the  floor  of  the  antrum,  its  future  site  should  be  freed  of  all  mucous 


Cr'dJJim 

Pig.  360.      Denker  operation  for  chronic  antraJ  infection. 

membrane;  otherwise  mucous  follicles  might  be  buried  under  it  and 
give  rise  to  cysts. 

The  next  step  in  the  Denker  operation  is  to  free  the  mucoperi- 
osteum  from  the  bony  wall  of  the  inferior  meatus  and  from  the  under 
surface  of  the  inferior  turbinate  bone.  Having  incised  the  mucoperi- 
osteum,  it  is  elevated  and  converted  into  a  flap,  to  be  turned  outward 
into  the  floor  of  the  antrum.  Finally,  the  bony  wall  of  the  inferior 
meatus,  with  the  mucous  covering  on  its  antral  side,  is  removed  with 
biting  forceps  (Fig.  361).  The  flap  of  nasal  mucoperiosteum  is  then 
turned  into  the  floor  of  the  nose  and  held  in  place  for  twenty-four  to 
forty-eight  hours  with  an  antiseptic  gauze  pack,  the  end  of  which  pro- 
trudes from  the  nostril.  The  wound  in  the  vestibule  of  the  mouth  is 
immediately  closed  with  sutures. 

In  doing  this  operation,  it  is  unnecessary  to  sacrifice  any  part  of  the 
inferior  turbinate  bone,  which  is  a  functioiial  structure.     Ballenger  Ccills 


DISEASES  OF  THE  MAXILLARY  SINUS. 


425 


attention  to  this  objection  in  almost  all  of  the  operations  that  give  per- 
manent intranasal  drainage.  In  the  few  cases  upon  which  we  have 
operated  for  chronic  antral  suppuration,  we  have  never  found  it  nec- 
essary to  remove  any  part  of  this  bone.  By  removing  the  outer  wall  of 
the  inferior  meatus  up  to  the  attachment  of  the  inferior  turbinate,  ample 
room  is  obtained.  In  making  the  window  into  the  inferior  meatus,  the 
lower  part  of  the  nasal  duct  may  be  injured.  It  opens  at  a  variable 
distance  below  the  attachment  of  the  inferior  turbinate  bone,  30  to  35 
millimeters  from  the  posterior  boundary  of  the  nostril,  which  is  about 
at  the  junction  of  the  anterior  with  the  middle  third  of  this  bone. 


Fig.  361.  Denker  operation  for  chronic  infection  of  tlie  antrum,  slaowing  the  per- 
manent opening  between  the  antrum  and  the  nasal  fossa  through  the  inferior  meatus. 
The  upper  dotted  line  indicates  the  height  to  which  the  lateral  wall  is  removed,  most 
of  the  opening  being  hidden  by  the  inferior  turbinated  bone. 

It  was  but  a  step  beyond  the  Denker  operation  for  the  rhinologist 
to  abandon  the  oral  route  and  to  open  the  antrum  at  the  anterior  in- 
ferior angle,  through  the  anterior  nares.  This  was  first  done  by  Can- 
field,  of  Ann  Arbor;  but  Ballenger,  objecting  to  the  sacrifice  of  any  of 
the  inferior  turbinate  bone,  modified  Canfield's  operation  accordingly. 
This  operation  he  presents  in  his  work  as  the  Canfield-Ballenger  oper- 
ation, and  to  the  mind  of  the  writer  represents  the  refinement  of  present- 
day  radical  operations  for  chronic  antral  suppuration,  but  will  give  no 
better  results  than  the  Denker  operation. 

CYSTS  OF  THE  ANTRUM. 

The  antrum  may  contain  free  mucus  from  simple  obstruction  of  its 
nasal  opening,  or  it  may  be  partially  or  completely  filled  by  a  mucous 


426  SURGERY  OF  THE  MOUTH  AND  JAWS. 

cyst,  due  to  the  distension  of  one  of  its  contained  mucous  follicles.  A 
dental  cyst  might  extend  into  the  antrum.  Occasionally  the  wall  of  the 
cyst  becomes  calcified  (Fig.  362).  The  mucus  will  obstruct  both  trans- 
mitted light  and  x-ray,  and  the  pressure  of  the  cyst  may  cause  pain. 
Later  a  cyst  may  thin  and  distend  the  walls  of  the  antrum.  It  is  to  be 
differentiated  from  chronic  suppuration  by  making  a  puncture. 

Treatment. — This  consists  in  furnishing  a  permanent  outlet  to 
the  mucus.  If  it  is  due  simply  to  the  closure  of  the  normal  outlet,  a 
supplementary  one  should  be  made  in  the  inferior  meatus.     If  the  dis- 


Fig.  362.  Calcified  wall  of  a  cyst  in  right  antrum,  communicating  with  the  socket 
of  two  bicuspid  teeth. — Hunterian  Museum,  London.  Photographed  for  this  book  by 
courtesy  of  the  curator. 

tension  is  due  to  a  cyst,  the  antrum  should  be  opened,  and  the  free  part 
of  the  cyst  wall  excised. 

TUMORS  OF  THE  ANTRUM. 

Fibromata,  osteomata,  or  sarcomata  may  arise  in  the  cavity  from 
its  walls ;  epitheliomata  from  its  contained  or  a  contiguous  mucosa ; 
odontomata,  cystic  or  solid,  or  a  tooth  may  grow  into  it.  Benign 
tumors  distend  or  cause  absorption  of  its  walls,  while  malignant  tumors 
infiltrate.  (For  symptoms  of  tumors  of  the  antrum  see  Examination, 
page  2.) 

Treatment. — Benign  tumors  are  to  be  removed,  after  opening 
the  antrum,  from  within  the  vestibule  of  the  mouth ;  while  malignant 
growths  will  demand  the  total  or  partial  removal  of  the  maxilla,  de- 
pending upon  their  size  and  location. 


CHAPTER  XXX. 

TUMORS  OF  THE  MOUTH  AND  JAW-BONES. 

Nearly  all  of  the  tumors  and  cysts  which  can  arise  in  any  part  of 
the  body  may  be  found  in  or  around  the  mouth,  except  those  which 
are  pecuHar  to  certain  extraneous  organs.  There  are  also  certain 
tumors  and  cysts  which  are  peculiar  to  this  region. 

HYPERTROPHY  OF  THE  GUMS. 

Though  probably  not  a  tumor  in  the  strict  sense  of  the  term,  it  is 
convenient  to  present  hypertrophy  of  the  gums  with  the  tumors  of  this 
part. 


Fig.   363.      Hyperlropliy  of  tlie  gums. — By  courtesy  of  Dr.  Prinz. 

The  gum  may  become  infiltrated  with  fibrous  tissue  and  enlarge 
until  the  teeth  are  buried  and  the  whole  mouth  is  filled.  It  appears 
usually  in  childhood,  and  all  of  the  cases  we  have  seen  or  heard  of  have 
been  in  children  or  young  adults. 

Cryer  illustrates  a  case  in  which  he  removed  the  gums,  alveolar 
processes,  and  teeth  in  both  jaws.  Fig.  363  presents  a  less-advanced 
case  from  the  service  of  Dr.  Hermann  Prinz.  In  case  of  this  severity, 
or  less,  we  have  excised  the  excess  tissue,  leaving  sufficient  of  the  mu- 
cosa to  cover  the  defect.  We  have  advised  that  the  patient  be  placed 
on  injections  of  Coley's  fluid,  as  used  for  sarcoma,  in  hope  that  this 
would  prevent  a  return  of  the  growth.     These  enlargements  are  some- 

427 


428  SURGERY  OF  THE  MOUTH  AND  JAWS. 

what  related  to  keloid,  and  one  cannot  rely  upon  their  not  continuing 
to  grow  after  removal.     Radium  or  the  x-ray  might  be  tried. 

Special  tumors  of  the  lip  and  tongue  will  be  presented  with  other 
affections  of  these   organs. 

MUCOUS  CYSTS. 

The  mucous  follicles  of  the  gums  may  become  distended  with  their 
secretions,  forming  small,  smooth,  elevated  nodules.  They  are  to  be 
treated  as  mucous  cysts  of  the  lip. 

EPULIS. 

This  is  a  rather  poor  term,  for  it  means  any  sort  of  tumor  on  the 
gums  (Fig.  364).  It  may  be  sessile  or  pedunculated,  and  may  be  of  in- 
flammatory origin — fibroma,  sarcoma,  myeloma,  angioma,  or  carcinoma. 


Pig.   364.      Giant  cell  epulis  in  a  negro  woman. 

In  most  instances  they  arise  from  the  edge  of  the  gum  at  the  neck 
of  a  tooth,  probably  most  often  from  the  root  membrane.  They  rarely, 
if  ever,  occur  behind  the  last  molar.  As  they  enlarge,  they  may  remain 
attached  to  a  narrow  stalk  or  grow  along  the  gum  and  between  the 
teeth.     Ulceration  may  occur  in  the  benign  tumors  from  irritation. 

The  myelomata,  as  they  grow  downward,  cause  an  expansion  of 
bone.  The  giant  cell  epulis  is  softer,  more  vascular,  bleeds  more  easily 
than  the  fibrous  epulis.  It  is  spongy,  of  irregular  contour  and  con- 
sistence, grows  more  rapidly,  and  is  more  common. 

Treatment. — They  should  be  removed  and  subjected  to  a  care- 
ful microscopical  examination.  If  pedunculated,  the  portion  of  the 
peridental  membrane  or  bone  to  which  they  are  attached  should  also 
be  removed.  This  will  usually  necessitate  the  removal  of  one  or  several 
teeth. 

The  sessile  variety  requires  a  more  extensive  removal,  the  incision 


TUMORS  OF  THE  MOUTM  AND  jAW-BONES.  429 

extending  into  healthy  mucous  membrane,  and  it  is  safer  to  include  at 
least  a  scale  of  underlying  bone.  Pure  fibromata,  benign  tumors  com- 
posed exclusively  of  fibrous  tissue,  are  rather  rare,  but  fibrous  tissue  oc- 
curs in  various  proportions  in  many  of  the  sarcomata.  Many  of  these 
tumors,  supposed  to  be  simple,  show  by  their  subsequent  clinical  be- 
havior that  they  are  at  least  locally  malignant,  and  their  removal  in  all 
cases  should  be  thorough.  In  a  number  of  immense  tumors  of  the  jaw, 
preserved  in  the  Hunterian  Museum  of  London,  the  history  attached 
states  that  they  occurred  as  small  nodules  upon  the  gum,  were  re- 
peatedly removed,  and  recurred  several  times  in  the  course  of  years, 
growing  very  slowly,  but  later  taking  on  rapid  uncontrollable  growth 
that  eventually  destroyed  the  patient.  It  is  probable  that  they  would 
not  have  recurred  if,  at  any  time  during  their  period  of  slow  growth,  a 
thorough  removal  had  been  made  of  the  tumor  with  the  tissue  from 
which  they  grew.  If  the  microscopical  examination  shows  a  growth  to 
be  malignant,  the  removal  should  be  planned  accordingly;  but  unfor- 
tunately the  clinical  outcome  of  some  of  these  growths  is  not  always 
to  be  determined  in  this  way,  and  the  only  safe  plan  is  to  remove 
thoroughly,  with  a  block  of  the  healthy  tissue  to  which  they  are  at- 
tached. 

LIPOMA. 

Lipoma,  angioma,  and  cirsoid  aneurysm  are  very  rarely  found  in 
connection  with  the  jaws,  and  a  special  presentation  of  them  is  not  nec- 
essary. 

FIBROMA. 

Besides  the  pedunculated  form  which  comes  under  the  general  term 
of  epulis,  fibromata  may  develop  either  from  the  periosteum  or  from 
fibrous  tissue  contained  within  the  bone.  In  the  former  case  it  will 
appear  as  a  slow-growing  nodule,  attached  by  a  broad  base;  in  the 
latter  it  will  cause  expansion  and  finally  perforation  of  the  bone.  They 
often  appear  to  arise  in  connection  with  some  trauma  and  grow  very 
slowly.  The  diagnosis  is  made  mostly  on  their  slow  growth  and  distinct 
nodular  outline,  also  on  their  consistence,  which  is  less  hard  than  bone 
or  cartilage.  All  new  growths  should  be  regarded  with  suspicion  and, 
wherever  possible,  subjected  to  microscopical  examination.  If  the 
tumor  takes  on  active  growth,  it  should  be  treated  as  malignant  and 
removed  with  a  section  of  the  bone  to  which  it  is  attached,  but  the  full 
thickness  of  the  lower  jaw  is  seldom  to  be  removed.  (There  is  a 
special  form  of  fibroma,  known  as  the  nasopharyngeal  polyp,  which  will 
be  described  with  tumors  of  the  pharynx,  and  under  the  heading  of 
Retromaxillary  Tumors.) 


430  SURGERY  OF  THE  MOUTH  AND  JAWS. 

CHONDROMA. 

A  chondroma  is  a  tumor  composed  of  hyaline  cartilage  and,  accord- 
ing to  Bland-Sutton,  grows  from  preexisting  cartilage;  occurring  in 
relation  to  the  upper  jaws,  they  may  arise  from  the  cartilaginous 
septum  of  the  nose.  They  are  encapsulated  and  non-malignant,  and 
cause  distress  only  by  their  size  and  relations.  They  occur  most  com- 
monly in  children  and  young  persons  and  are  usually  small,  but  may 
rarely  attain  a  relatively  large  size.  Pathogenically  they  are  to  be  dis- 
tinguished from  the  more  rapidly  growing,  infiltrating  chondrosarco- 
mata,  which  grow  to  a  large  size.  They  should  be  excised  with  the 
cartilage  from  which  they  grow. 

OSTEOMA. 

These  tumors  are  composed  of  bone,  surrounded  by  a  layer  or  cap 
of  cartilage — therefore,  ossifying  chondromata.     They  occur   on   any 


Fig.   365.      Osteoma  of  ivory-like  texture,   attached  to  the  angle  of  the  lower  jaw. — 
Hunterian  Museum,  London.     Photographed  for  this  book  by  courtesy  of  the  curator. 

part  of  the  bones  of  the  face,  but  probably  more  commonly  on  the  upper 
than  the  lower  jaw.  They  may  be  of  compact  or  cancellous  bone,  and 
may  be  pedunculated  or  attached  by  a  broad  base.  They  grow  very 
slowly,  but  may  attain  a  large  size.  As  they  grow,  the  soft  tissues 
covering  them  may  ulcerate,  leaving  the  bone  exposed.  They  are  pain- 
less, but  pain  may  be  caused  by  pressure.  When  pedunculated,  they 
may  become  detached  and  be  thrown  off  spontaneously.  They  are 
non-malignant  (Fig.  305).  Detached  bony  masses  have  been  found  in 
a  soft  tumor — possibly  a  sarcoma  (Fig.  366).  They  are  to  be  distin- 
guished from  osteo-  or  bone-forming  sarcomata,  from  tumors  that 
expand  the  bone,  and  from  leontiasis  ossea,  which  latter  is  a  thickening 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES. 


431 


of,  not  a  growth  from,  the  bone.     Treatment  consists  in  their  removal, 
together  with  ar  very  small  area  of  the  bone  to  which  they  are  attached. 

MYXOMA. 

The  pure  myxoma  is  rare.  Myxosarcoma,  which  is  more  common, 
is  a  flat,  soft  tumor  of  much  more  rapid  growth.  The  indications  are 
for  a  complete  removal,  rather  than  a  partial  operation. 

ODONTOMA. 

Under  this  heading  are  included  a  number  of  benign  tumors  and 
cysts  which  arise  from  the  teeth  germs  during  the  process  of  growth, 
and  are  composed  of  dental  tissues  in  varying  proportions.  These  have 
been  classified  by  Bland-Sutton  according  to  their  structural  peculiar- 
ities as  follicular  and  fibrous  odontomata,  cementomata,  compound  folH- 


Pig.  366.  True  osseous  fragments  removed  from  a  soft  tumor  in  the  antrum,  from 
a  girl  of  11  years.  There  is  nothing  to  show  that  this  is  in  any  way  connected  in  its 
origin  with  the  tooth  sacs.  (Bland-Sutton:  Transactions  of  the  Odontological  Society 
of  Great  Britain,  Vol.  xxxiv,  Njo.  4,  page  96,  2197  E.  A.) — Hunterian  Museum,  Lon- 
don.    Photographed  for  this  laook  by  courtesy  of  the  curator. 

cular  odontomata,  radicular  odontomata,  and  composite  odontomata. 
There  are  some  strong  reasons  for  placing  cystic  adamantinomata 
among  the  odontomata,  but  we  have  followed  Bland-Sutton's  classifi- 
cation and  presented  them  with  the  endotheliomata. 

Follicular  Odontoma. — Ordinarily,  at  a  certain  stage  of  develop- 
ment, the  tooth  sac  in  which  the  tooth  has  developed  is  pierced,  and  the 
tooth  erupts.  If  for  some  reason  this  last  stage  of  dentition  fails  to 
occur,  the  ill-developed  tooth  will  remain  in  the  bone,  enveloped  by  a 
fibrous  capsule,  which  usually  also  contains  a  viscid  fluid.  The  thick- 
ness of  this  capsule  varies  and  it  may  contain  bony  spicules.  The 
tooth  itself  may  be  absent  or  represented  by  a  denticle.  Follicular 
odontomata  are  most  common  in  connection  with  the  permanent 
molars  and  may  be  multiple   (Fig.  367). 


432 


SURGERY  OP  TME  MOUtH  AND  JAWS. 


Fibrous  Odontoma. — If  the  tooth  sac  becomes  very  much  thick- 
ened, the  unerupted  tooth  may  be  found  in  a  mass  of  fibrous  tissue  and 
much  deformed. 

Compound  Follicular  Odontoma. — Sometimes  the  thickened 
capsule  ossifies   sporadically,   in   which   case   it   will   contain   denticles 


Fig.    368. 


Fig.    369. 


Fig.    370. 


Fig.  367.  Follicular  odontoma.  It  is  possible  that  this  Is  simply  a  retained  tooth 
in  a  sac  thickened  by  inflammation. — Hunterian  Museum,  London.  Photographed  for 
this   book   by   the   courtesy   of   the   curator. 

Fig.  368.  Odontomata  composed  of  cementum  traversed  by  irregular  canals  resem- 
bling the  Haversian  canals.  Removed  from  the  molar  region  of  one  side  of  the  mandi- 
ble. Tumor  appeared  at  11  years ;  was  operated,  on  account  of  the  deformity,  at  15 
years,  at  16yo  years,  and  at  19  years.  The  last  operation  was  followed  by  cure. 
(J.  Ward  Collins,  British  Med.  Journal,  June  6th,  1908). — Hunterian  Museum,  London 
Photographed  for  this  book  by  courtesy  of  the  curator. 

Fig.  369.  Cemeiitonia  in  a  girl,  16  years  of  age.  Had  been  noticed  for  four  years 
and  gradually  enlarging.  Probably  of  Inflammatory  origin.  A  provisional  diagnosis  of 
odontoma  was  made,  based  on  the  fact  that  the  tooth  was  not  loose. 

Fig.   370.      Composite  odontoma,  after  Gilmer. 


composed  of  one  or  all  three  of  the  tooth  elements ;  dentin,  cementum, 
and  enamel.  The  follicular  and  fibrous  odontomata  are  collectively 
termed  dentigerous  cysts. 

Cementoma. — If  the  thickened  capsule  described  above  ossifies, 
the  tooth  will  be  found  imbedded  in  a  mass  of  cementum.     Such  tumors 


TUMORS  OF  THE  MOUTH  ANU  JaW-GoKES. 


433 


are  common  in  horses,  but  according  to  Bland-Sutton,  do  not  occur 
in  man    (  Fig'.'  ;)()8  ). 

Radicular  Odontoma. — A  radicular  odontoma  is  a  tumor  which 
arises  from  the  root  portion  of  the  tooth  and  therefore  can  contain 
only  dentin  and  cementum.  There  is  reason  to  believe  that  some 
osseous  swellings  connected  with  the  roots  of  teeth  may  be  of  in- 
flammatory origin;  the  distinguishing  feature  of  these  being  that  the 
roots  are  imbedded  in  a  circumscribed  mass  of  bone,  but  the  tissues  of 
each  are  distinct  and  separate  and  do  not  merge  into  each  other  (Fig. 
369). 

Composite  Odontoma. — Under  this  head  are  included  all  hard 
tooth  tumors  which  present  a  disorderly  conglomeration  of  cementum. 
dentin,  and  enamel  in  varying  proportions.     They  might  be  considered 


Fig.    371. 


Fig.    372. 


Fig.  371.  Cystic  tumor  of  the  left  side  of  the  body  of  the  lower  jaw,  containing 
a  cuspid  tooth.  The  cyst  was  lined  with  granulation.  Probably  of  inflammatory  origin. 
From  patient,  13  years  of  age.  One  half  of  the  jaw  was  excised,  under  the  impression 
that  it  was  a  tumor.  (See  British  Med.  Journ.  Vol.  1,  1864,  page  241,  and  Injuries  and 
Diseases  of  the  Jaw — Heath,  2d  Ed.,  page  165.) — Hunterian  Museum,  London.  Photo- 
graphed for  this  book  by  courtesy  of  the  curator. 

Fig.  372.  Bone  cyst  following  infection  of  upper  lateral  incisor  teeth.  The  arrow 
points  to  the  expanded  bony  wall  of  the  cyst. 

as  the  product  of  an  abnormal  growth  of  all  of  the  elements  of  a  tooth 
germ  and  might  represent  two  or  more  tooth  germs  fused  into  one 
mass  in  which  no  normal  individual  tooth  is  found.  They  vary  much 
in  shape,  are  rough  in  outline,  and  may  attain  considerable  size.  One 
weighing  885  grains,  preserved  in  the  Royal  Dental  Hospital,  is  proba- 
bly the  largest  on  record    (Fig.   370). 

Gilmer,  who  has  had  a  large  personal  observation  of  cases  of  odon- 
toma, takes  exception  to  Broca's  and  Bland-Sutton's  classifications, 
maintaining  that  they  are  too  broad. 

He  would  include  under  the  head  of  odontomes  only  tumors  that 
are  composed  of  nests  of  aberrant  tooth  forms,  ununited  by  cement,  but 


434 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


inclosed  in  a  fibrous  capsule,  similar  masses  held  together  by  granular 
calcific  matter  that  resembles,  imperfectly,  cement,  and  those  classified 
by  Bland-Sutton  as  composite  odontomata.  His  observations  led  him 
to  believe  that  these  seldom,  if  ever,  represent  or  do  they  replace  a 
normal  tooth,  but  that  they  are  derived  from  some  other  source. 

He  would  exclude  from  the  classification  of  odontomes  single  teeth 
that  are  simply  deformed,  teeth  more  or  less  perfectly  developed  re- 
maining in  a  fibrinous  capsule  (Fig.  367),  or  imbedded  in  a  mass  of 
cementum  (Fig.  369),  tumors  of  other  tissues,  caused  by  the  teeth 
(Figs.  371  and  372),  and  also  cystic  adamantinomata  (Figs.  374  and 
375). 

Odontomata,  dentigerous  cysts,  etc.,  are  usually  observed  in  young 
persons  and  are  supposed  to  occur  more  frequently  in  the  lower 
than  the  upper  jaw.  _  When  of  considerable  size,  they  may  cause  a 
thickening  that  can  be  felt  or  seen.  It  has  been  observed  that  some 
of  them  have  a  tendency  to  erupt  like  teeth,  and  this  is  when  they  are 


Fig.   373.      Supernumerary  teeth  in  a  boy,  15  years  of  age. 

most  apt  to  cause  symptoms.  If  the  bed  of  the  tumor  becomes  infected, 
there  will  be  a  purulent  discharge,  and  at  this  stage  the  tumor  has  been 
frequently  mistaken  for  necrosed  bone.  The  sepsis  resulting  may  be 
very  severe.     The  x-ray  is  useful  in  detecting  the  mass. 

Treatment  of  Odontoma. — The  treatment  consists  in  simply  re- 
moving the  tumor;  mutilating  excisions  of  a  portion  of  the  jaw  are 
in  no  way  indicated.  With  the  follicular  variety  it  is  usually  sufficient 
to  remove  one  bony  wall,  scrape  out,  and  pack  the  cavity.  The  solid 
tumors  are  to  be  removed,  after  removing  sufficient  bone  on  one  side 
to  permit  of  their  being  lifted  out  with  an  elevator. 
SUPERNUMERARY  TEETH. 

The  occurrence  of  supernumerary  teeth  is  not  uncommon.  In  most 
instances  it  is  probably  an  atavistic  recurrence  of  some  tooth  that  has 
been  suppressed  in  the  human — such  as  a  central  incisor,  premolar,  or 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES.  435 

fourth  molar.  Such  teeth  are  usually  well-formed.  Sometimes  there 
is  an  ill-forme'd  tooth  that  might  have  been  developed  from  a  "rest." 
Zukerkandl  found  enamelless  tooth  rudiments  in  the  incisor  region  in 
twenty  out  of  six  hundred  crania  examined.  Black  and  many  others 
have  observed  instances  in  which  there  were  additional  buds  given  off 
from  the  dental  strand.  It  is  possible  that,  after  giving  off  the  normal 
number  of  buds,  the  dental  strand  may  not  always  become  absorbed, 
and  it  might  go  on  producing  tooth  buds  indefinitely.  Such  might  be 
the  explanation  of  those  rare  cases  where  an  enormous  number  of 
denticles  have  been  repeatedly  removed  from  the  same  jaw.  It  is  very 
rare  that,  where  there  are  a  number  of  supernumerary  teeth,  they  are  as 
well  formed  as  in  the  case  shown  in  Fig.  373. 

DENTAL  CYSTS. 

This  is  a  term  which  is  to  be  always  regarded  with  suspicion,  it 
being  often  used  to  indicate  an  absorption  abscess  or  a  dentigerous 
cyst  or  follicular  odontoma,  but  there  is  a  pathological  condition  that 
can  be  properly  placed  under  this  designation.  Occasionally  there  is 
found  in  connection  with  the  root  of  a  dead  permanent  tooth  a  fibrous 
sac,  which  may  vary  in  size  from  an  apple  seed  to  a  small  egg.  It 
contains  fluid  and  often  cholesterin  crystals.  These  cysts  have  been 
regarded  as  inflammatory,  but  J.  G.  Turner  has  demonstrated  an  epi- 
thelial lining  in  many  of  them  and  believes  them  to  have  developed 
from  a  peridental  epithelial  remnant.  They  may  form  painless,  smooth 
tumors,  which  in  the  upper  jaw  may  invade  the  antrum.  The  extent 
of  the  cysts  is  best  determined  by  the  x-ray.  The  smaller  cysts  require 
no  treatment  after  the  removal  of  the  tooth  to  which  they  are  attached. 
Larger  ones  may  require  the  removal  of  several  teeth.  The  cavity 
should  be  scraped  out,  and  one  bony  wall  may  be  removed.  If  the  cyst 
involves  only  the  apices  of  the  teeth,  it  may  be  invaded  laterally,  and 
the  roots  within  the  cavity  amputated.  (See  Treatment  of  Alveolar 
Abscess,  Chap.  XXVII.) 

SARCOMA. 

Sarcoma  is  a  general  term  given  to  non-encapsulated  tumors  of  any 
of  the  connective  tissues,  fibrous  tissue,  bone,  muscle,  etc.,  which  tend 
to  infiltrate  neighboring  tissues  and  to  spread  to  distant  parts  of  the 
body  through  the  blood  stream.  This  habit  of  invading  neighboring 
and  distant  tissues  constitutes  malignancy.  Benign  tumors  push  neigh- 
boring tissues  before  them  or  cause  their  absorption  by  simple  pressure, 
and  they  never  cause  distant  infections. 

Several  varieties  of  sarcoma  occur  in  connection  with  the  jaws. 
Including  the  sarcomatous  epulis,  sarcoma  is  the  most  common  variety 
of  tumor  of  the  lower,  and  next  to  carcinoma,  the  most  common  tumor 


436  SURGERY  OF  THE  MOUTH  AND  JAWS. 

of  the  upper  jaw.  They  may  be  of  the  spindle,  large,  or  small  round 
cell,  or  the  somewhat  doubtful  alveolar  variety;  or  the  growth  may  be 
mixed  in  the  character  of  the  cells  which  compose  it.  Any  of  them 
may  contain  sufficient  fibrous  tissue  to  make  this  a  characteristic  of  the 
growth,  or  they  may  form  bone  or  cartilage.  Rarely,  melanotic  sar- 
comata of  the  upper  jaw  have  been  observed.  The  histological  character 
will  often  give  some  clew  to  their  virulency.  The  large  round,  the 
spindle,  and  the  small  round  varieties  vary  in  malignancy  in  the  order 
named,  the  large  round  cell  tumor  being  least  so.  The  greater  the  pro- 
portion of  fibrous  tissue,  the  less  the  malignancy.  The  sarcomata  that 
form  fibrous,  osseous,  or  cartilaginous  tissue  are  composed  of  cells 
which  have  the  power  of  developing  beyond  the  purely  embryonal 
stage,  and  it  is  probable  that  they  are  in  general  less  malignant.  Mela- 
notic sarcomata  are  the  most  malignant  of  all.  The  relation  of  the  cells 
to  the  blood  vessels  seems  to  have  some  bearing  on  this  subject,  those 
tumors  in  which  the  cells  are  crowded  close  to  the  vessels  being  more 
malignant  than  tumors  in  which  the  cells  are  separated  from  the  vessels 
by  some  fibrous  tissue. 

Sarcomata  may  arise  from  the  gums,  the  antrum,  the  surface  peri- 
osteum, root  membrane,  or  from  within  the  alveoli  of  the  bone.  If 
the  sarcoma  is  in  the  upper  jaw,  it  most  often  starts  in  the  antrum. 
The  hard  palate  and  frontal  process  of  the  upper  jaw  are  least  often 
involved.  Sarcomata  arising  from  the  periosteum  are  usually  rather 
firm  in  consistency,  while  those  arising  from  within  the  bone  are  often 
very  soft.  Scudder  states  that  periosteal  sarcoma  does  not  arise  in 
the  alveolar  border,  but  from  the  body  of  the  bone.  It  is  often  stated 
that  the  periosteal  varieties  are  less  malignant  than  those  of  endosteal 
origin.  This,  however,  seems  not  to  take  into  account  myeloma,  which 
is  the  most  frequent  of  the  endosteal  tumors,  and  which  is  only  locally 
malignant.  Scudder  claims  that  the  periosteal  round  and  spindle  cell 
sarcomata  are  very  malignant. 

A  sarcomata  arising  within  a  tooth  socket  causes  first  a  loosening, 
later  a  loss  of  the  tooth,  and  is  then  inclined  to  fungate  from  the  cavity. 
The  periosteal  varieties  cause  hard,  irregular,  usually  somewhat  fusiform 
swellings.  The  myelomata  grow  within  the  bone  and  cause  a  thinning 
and  often  irregular  bulging  of  its  walls,  but  can  also  cause  a  thickening 
of  the  gum  tissue.  Certain  of  the  true  sarcomata,  which  grow  within 
the  body  of  the  bone,  cause  a  thinning  and  bulging  rather  than  infiltra- 
tion of  its  walls ;  and  from  personal  observation,  we  are  certain  that 
they  are  among  the  more  mildly  malignant.  In  the  upper  jaw  peri- 
osteal sarcomata  may  arise  within,  or  endosteal  sarcomata  may  invade 
the  maxillary  antrum,  causing  at  first  a  thinning  and  bulging  of  its 
walls,  but  later  a  perforation  and  involvement  of  the  soft  tissues  by 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES.  437 

direct  extension.  Sarcomata  of  the  mouth  may  cause  enlargement  of 
the  lymph  nodes,  but  with  the  exception  of  the  lymphosarcomata,  more 
often  from  septic  absorption  from  the  ulcerated  surface  than  from  an 
extension  of  the  disease.  Sarcomata  seldom  cause  pain,  at  least  in 
the  earlier  stages,  though  they  may  do  so  by  pressure  on  nerve  trunks. 
The  diagnosis  should  always  rest  upon  a  microscopical  examination,  to 
which  it  is  a  safe  plan  to  subject  every  tumor.  The  various  clinical 
symptoms  which  are  ascribed  to  different  tumors  and  different  varieties 
of  sarcomata  may  be  misleading  in  the  individual  case,  and  if  depended 
upon  for  a  diagnosis,  may  cause  unnecessary  mutilation  or  a  disastrous 
delay.  We  have  seen  an  adenocarcinoma  in  a  girlof  twenty  years  which 
clinically  appeared  to  be  a  sarcoma,  but  which  had  already  infected  the 
lymph  nodes.  In  another  case,  its  sarcomatous  nature  was  entirely  over- 
looked because  there  was  little  evidence  of  growth  and  a  very  extensive 
necrosis  of  one  half  of  the  body  of  the  lower  jaw.  A  microscopical 
examination  of  some  hard  granulations  which  lined  the  cavity  proved 
its  true  character.  No  age  is  exempt  from  this  disease.  Coley  at- 
tributes acute  trauma  as  a  cause  in  23  per  cent  of  his  970  cases.  Some 
fungate  and  ulcerate  early,  while  others  attain  immense  size  without 
ulcerating.  In  some  varieties  the  growth  is  rapid  from  the  first ;  while 
in  others  it  may  be  slow  or  remain  in  abeyance  for  years,  only  to  take 
on  a  rapid  growth. 

Treatment. — With  the  exception  of  the  myelomata  and  certain 
slow-growing,  large  round  cell  varieties,  the  treatment  of  all  operable 
tumors  is  a  radical  excision  en  masse,  of  all  involved  tissues  well  into 
the  healthy  structures.  The  lymph  sarcomata  will  demand  the  removal 
of  the  lymph-bearing  tissue  of  the  regions  which  drain  the  infected 
area.  It  is  not  always  necessary  or  advisable  to  remove  a  whole  or 
half  of  the  jaw-bone,  but  the  excision  should  be  made  from  1  to  iy2 
centimeters  from  the  tumor  all  around,  regardless  of  the  tissue  involved ; 
and  where  possible,  the  lower  border  of  the  bone  should  be  preserved. 
After  removing  the  mass,  the  excised  portion  of  the  jaw  should  be 
sawed  immediately  and  examined.  If  the  excision  has  not  been  made 
sufficiently  far  beyond  the  growth,  a  further  excision  can  be  made. 
(For  Excision  Operations  on  the  Gums  and  Jaws,  see  Chap.  XXXI.) 

If  too  far  advanced  to  attempt  radical  treatment,  the  operation 
should  be  made  as  complete  as  possible,  as  some  of  these  growths, 
especially  the  large  round  cell  variety,  return  very  slowly  after  an  in- 
complete removal.  This  may  be  true  even  of  the  mixed  small  and 
spindle  cell  tumors.  In  large  slow-growing  tumors  of  the  lower  jaw 
which  cause  a  distinct  expansion  of  bone  and  can  apparently  be  shelled 
out  of  the  bone,  we  believe  that  this  is  a  better  treatment  than  a  very 
extensive  resection.     Such  tumors  are  usually  composed  of  large,  round 


438  SURGERY  OF  THE  MOUTH  AND  JAWS. 

cells  and  much  fibrous  tissue,  and  are  slow  to  return  after  being  re- 
moved in  this  way.  The  lateral  bony  walls  of  the  cavity  may  be  excised 
with  their  periosteal  covering,  but  at  least  a  thin  bridge  of  bone  should 
remain  to  preserve  the  outline  of  the  lower  jaw.  Gilmer  has  reported 
a  number  of  satisfactory  results  with  such  tumors  treated  in  this  way. 
In  all  cases  we  would  recommend  the  use  of  Coley's  fluid,  pushed  to 
the  limit  of  endurance  for  a  long  period  after  every  attempted  re- 
moval of  a  sarcoma.  We  have  had  the  satisfaction  of  seeing  several 
inoperable,  or  unoperated,  sarcoma  held  in  abeyance  for  a  number  of 
years,  after  the  use  of  the  Coley's  fiuid.  (We  have  found  the  fluid  pre- 
pared by  Dr.  Martha  Tracy  the  most  active.)  If  accessible,  radium 
may  be  used.  The  x-ray  may  be  applied  in  the  mouth  through  a  Fer- 
guson vaginal  speculum. 

In  all  cases  of  sarcoma  the  ultimate  prognosis  is  bad,  even  if  re- 
moved early.  But  recurrence  may  not  take  place  for  a  long  time,  or 
the  patient  may  die  from  metastasis  of  the  lungs  before  there  is  local 
recurrence.  However,  metastasis  from  jaw  sarcomata  is  rarer  than 
from  other  sarcomata. 

Starvation  Treatment  of  Inoperable  Sarcomata. — The  idea  of 
treating  tumors  by  limiting  their  blood  supply  is  an  old  one.  Dawbarn 
has  presented  a  treatise  on  the  subject  of  starvation  of  inoperable  tumors 
of  the  mouth  and  neck.  Judging  from  the  cases  reported  in  this  work, 
the  results  in  but  few  can  be  regarded  as  positive,  but  in  dealing  with 
inoperable  growths,  anything  that  may  modify  their  malignancy  must 
be  regarded  as  worthy  of  attention.  The  best  results  that  Dawbarn  has 
had  are  in  sarcomata,  and  in  those  that  were  limited  to  the  area  supplied 
by  the  external  carotid  artery.  In  several  of  these,  the  growth  of  the 
tumor  seems  to  have  been  stopped  for  an  indefinite  time.  The  only 
noticeable  result  we  have  observed  after  the  use  of  this  method  was  the 
shrinking  of  the  temporal  expansion  of  a  nasopharyngeal  polyp. 

The  branches  of  the  external  carotid  are  exposed  as  described  for 
ligating  this  vessel.  A  temporary  ligature  is  thrown  loosely  around 
the  trunk  of  the  external  carotid,  or  a  Crile  artery  clamp  is  placed  upon 
the  common  carotid  to  provide  for  accidental  tearing  of  the  vessels. 
The  superior  thyroid,  lingual,  facial,  occipital,  and  the  ascending 
pharyngeal,  if  it  can  be  found,  are  caught  in  turn  with  Halsted  artery 
forceps,  doubly  ligated,  and  then  cut.  The  bellies  of  the  stylohyoid 
and  digastric  muscles  are  drawn  upward.  Into  the  trunk  of  the  ex- 
ternal carotid  is  injected  6  cubic  centimeters  of  melted  wax  at  low 
melting  point,  six  parts  white  wax  with  four  parts  olive  oil.  This  fills 
and  blocks  the  posterior  auricular,  internal  maxillary,  and  temporal  ar- 
teries. After  this  injection  one  should  be  able  to  feel  the  wax  in  the 
temporal  artery.     Two  weeks  later  the  operation  should  be  repeated 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES.  439 

on  the  opposite  side.  In  our  experience,  several  times  after  primary 
healing  of  the  neck  wound,  a  fistula  has  appeared  and  persisted  for 
several  weeks  or  months,  with  discharge  of  pieces  of  the  wax. 

MYELOMA. 

These  were  formerly  classed  as  sarcomata,  but  are  not  malignant  in 
that  they  do  not  cause  metastasis  and  will  not  recur  after  a  thorough 
removal.  They  arise  only  in  the  alveolar  tissue  of  the  bone  and  are 
composed  for  the  most  part  of  giant  cells,  with  an  intermixing  of 
spindle  and  round  cells.  The  tumor  presents  the  appearance  of  freshly 
cut  liver.  According  to  Bland-Sutton,  they  occur  in  the  body  of  the 
mandible  and  the  alveolar  process  of  the  maxilla.  They  rarely  occur 
after  the  age  of  twenty-five,  grow  slowly,  and  expand  the  bone  as  they 
advance.  Sometimes  they  later  perforate  the  bony  capsule  and  invade 
the  soft  tissues. 

The  diagnosis  of  myeloma  rests  upon  the  clinical  features  cited,  and 
a  microscopical  examination.  For  their  treatment  they  do  not  require 
mutilating  operations ;  but  the  bone  is  to  be  opened,  and  the  tissues 
scraped  out.  If  they  have  perforated  the  capsule,  this  portion  should 
be  removed  by  an  excision  extending  into  the  healthy  tissue.  A  deep 
bone  cavity  resulting  from  the  removal  of  a  myeloma  had  best  be 
treated  according  to  the  principles  laid  down  for  cavities  resulting  from 
bone  abscess  of  the  jaw  (Chap.  XXVII). 

ENDOTHELIOMA. 

Endotheliomata  are  tumors  arising  from  the  endothelium  of  the 
blood  vessels  and  lymphatics.  As  endothelial  tissue  originates  from  the 
same  germinal  layers  as  does  connective  tissue,  these  tumors  are  related 
to  sarcomata  and  often  behave  like  them.  One  form  of  tumor  which 
has  been  described  as  alveolar  sarcoma,  which  may  be  very  malignant, 
is  probably  of  endothelial  origin.  In  the  jaws  alveolar  sarcomata 
should  be  treated  as  other  sarcomata.  It  is  probable  that  many  of  the 
so-called  cystom.ata  of  the  jaw-bones  are  of  endothelial  origin. 

MULTILOCULAR  CYSTIC  TUMORS. 

The  cysts  contain  brown  mucous  fluid,  and  the  septa  between  them 
may  ossify  (Fig.  375).  The  growing  portions  of  the  tumor  may  some- 
what resemble  a  myeloma.  These  tumors  are  most  common  about  the 
age  of  twenty  years,  but  they  may  be  met  with  much  later.  Eve  la- 
beled them  multilocular  cystic  epithelial  tumors  of  the  jaw,  and  they 
have  been  supposed  to  have  their  origin  in  the  enamel  organ.  They 
occur  about  twice  as  frequently  in  females  as  in  males.  They  are 
found  most  generally  in  the  lower  jaw  near  the  angle.     They  are  also 


440  SURGERY  OF  THE  MOUTH  AND  JAWS. 

known  as  adamantinomata,  and  it  has  been  positively  asserted  that  the 
cells  of  an  enamel  organ  can  be  demonstrated.  Bland-Sutton  states  that, 
though  he  formally  accepted  this  view,  he  now  considers  them  as  endo- 
theliomata  arising  from  the  gums.  Between  the  opinions  of  such 
observers  as  Eve  and  his  followers  on  the  one  hand  and  of  Bland-Sutton 
on  the  other,  we  would  not  presume  to  judge,  but  our  great  respect  for 
the  latter's  knowledge  of  tumors,  in  general,  leads  us  to  place  them  under 
the  heading  of  endotheliomata.  These  may  attain  a  large  size,  are  at 
least  locally  malignant,  and  should  be  completely  removed. 

CARCINOMA. 

About  the  throat  and  nose,  where  ciliated  epithelium  is  found,  this 
variety  is  first  replaced  by  squamous  epithelium  before  it  shows  recog- 


Fig.    374.  Fig.    375. 

Pig.  374.  Cystic  adamantioma,  from  middle-aged  man.  Tumor  liad  been  present 
several  years.  (For  one  of  the  early  descriptions  of  cystic  tumors  of  the  jaws,  see 
British  Med.  Journ.,  Vol.  1,  1883,  page  1.) — Hunterian  Museum,  London.  Photo- 
graphed for  this  book  by  courtesy  of  the  curator. 

Fig.  375.  Multilocular  cystic  tumor,  the  septa  being  composed  of  fibrous  tissue  and 
bone.  Probably  of  the  same  character  as  the  preceding.  Bland- Sutton  would  ascribe 
this  tumor  to  endothelial  origin. — Hunterian  Museum,  London.  Photographed  for  this 
boolt  by  courtesy  of  the  curator. 

nized  signs  of  malignancy.  Unless  due  to  an  extension  from  the  lips 
or  cheeks,  carcinoma  of  the  jaw  is  almost  exclusively  a  disease  of 
elderly  persons.  It  can  arise  from  epithelium,  and  in  most  instances 
comes  primarily  from  the  mucous  covering  of  the  gums  or  the  lining 
of  the  antrum.  Schlatter  cites  one  case  in  his  practice  where  the  tumor 
arose  within  the  body  of  the  lower  jaw,  apparently  metastatic  from  a 
cancer  of  the  breast  that  had  been  removed  three  and  a  half  years  pre- 
viously. The  common  site  of  primary  cancer  of  the  upper  jaw  is 
within  the  antrum. 

Of  the  tumors  which  arise  within  the  mouth,  most  of  them  seem  to 
be  in   connection  with  dental  or  mechanical   irritations.     Leucoplakia 


TUMORS  OF  THE  MOUTH  AND  JAW-EONES.  441 

is  responsible  for  some,  and  in  this  connection  smoking  must  be  re- 
garded as  a  factor.  In  a  number  of  cases  the  disease  is  an  extension 
from  the  hp  or  cheek.  Broadly,  there  are  two  clinical  types  of  carci- 
noma of  the  jaws:  the  hard,  ulcerating  tpye,  which  usually  appears  on 
the  lower  jaw;  and  the  soft,  medullary  carcinoma,  which  is  found  in 
the  antrum  and  upon  the  oral  surface  of  the  upper  jaw.  The  symptoms 
of  these  two  differ  materially.  The  hard  ulcerating  tumor  grows  more 
slowly  and  in  the  earlier  stage  causes  no  pain.  The  induration  and 
ulceration  invade  the  neighboring  surfaces  much  more  rapidly  than  the 
deep  tissues,  but  we  have  seen  a  thin  tongue  of  carcinoma  extending 
down  under  the  periosteum  for  1  centimeter  beyond  the  evident  indura- 
tion. The  induration  of  this  type  is  usually  of  a  hardness  that  is  un- 
mistakable. 

When  seen  upon  the  oral  surface,  the  medullary  carcinoma  is  usually 
very  soft,  and  is  first  noticed  as  a  small  papule,  which  may  bleed  easily. 
As  it  extends,  it  may  take  on  a  cauliflower  appearance.  It  rapidly 
extends  both  on  the  surface  and  into  the  antrum,  but  does  not  ulcerate 
early.  In  tumors  arising  in  the  antrum  or  nasal  cavity,  pain  is  an  early 
and  almost  constant  symptom.  This  may  be  localized  in  the  form  of  a 
toothache,  or  diffused  over  the  distribution  of  the  fifth  cranial  nerve. 
As  the  tumor  enlarges,  there  are  symptoms  of  obstruction  of  the  nasal 
fossa  and  of  the  nasal  duct.  The  cheek  becomes  prominent,  and  when 
the  external  bony  wall  is  perforated,  the  tumor  may  be  felt  in  the  soft 
tissues  of  the  cheek.  The  skin  may  become  discolored,  but  rarely 
ulcerates.  The  tumor  may  fungate  into  the  mouth.  These  tumors 
usually  invade  the  orbit,  causing  exophthalmos,  with  or  without  im- 
pairment of  vision. 

Carcinoma  of  the  lower  jaw  causes  earlier  evident  involvement  of 
the  lymph  nodes  than  does  carcinoma  of  the  upper  jaw.  This  may 
be  due  to  the  fact  that  most  of  the  lymphatics  leading  from  the  upper 
jaw  empty  into  the  internal  maxillary  and  retropharyngeal  nodes,  which 
are  not  palpable.  Inability  to  palpate  enlarged  lymph  nodes  in  the  neck 
should  never  he  taken  as  evidence  that  they  are  not  involved. 

The  diagnosis  of  the  hard,  ulcerating  carcinoma  is  usually  not 
difficult  from  the  clinical  picture  and  its  chronicity,  but  a  microscopical 
examination  of  the  tissue  should  never  be  omitted.  The  medullary 
carcinoma  when  situated  on  the  oral  surface  should  be  subjected  to  the 
same  examination. 

The  malignancy  of  medullary  carcinoma  when  at  all  advanced  is 
always  evident  from  the  rapidity  and  impartiality  with  which  it  invades 
all  tissues  with  the  exception  of  the  teeth  and  eyeballs.  Any  growing 
intramaxillary  tumor  should  be  investigated,  and  even  unaccountable 
pain  over  the  distribution  of  the  fifth  nerve  in  elderly  persons  should 


442  SURGERY  OF  THE  AlOUTH  AND  JAWS. 

lead  to  careful  examination  of  the  whole  area  of  its  distribution.  If  a 
piece  of  the  new  tissue  cannot  be  obtained  from  within  the  nasal  fossa, 
it  is  a  simple  matter  to  open  the  antral  cavity  through  the  canine  fossa 
so  that  a  digital  examination  can  be  made  and  a  piece  of  tissue  obtained. 

The  prognosis  of  carcinoma  of  the  body  or  surface  of  the  maxilla 
is  bad.  The  medullary  tumor  which  attacks  it  rapidly  invades  the 
neighboring  spaces,  and  the  lymphatics  are  out  of  the  reach  of  surgery. 
With  the  hard  carcinoma  of  the  surface  of  the  lower  jaw,  the  prognosis 
is  very  much  better.  If  seen  early,  it  may  be  rather  favorable  after  a 
proper  operation.  '  '  i  ■ 

Treatment.  The  older  method  of  treatment  consisted  of  some 
form  of  cauterization.  Later  this  was  condemned  for  the  supposedly 
more  efficient  anatomical  excision.  Gilmer,  later  Bloodgood  and  others, 
have  sounded  a  warning  of  conservatism  in  dealing  with  malignant 
tumors  of  the  mouth,  and  within  the  past  decade  the  pendulum  has 
swung  back  to  the  use  of  the  cautery  iron.  Now  it  is  used  at  a 
low  heat  as  suggested  indirectly  by  Percy  and  the  cauterization  is  kept 
up  for  a  long  time,  a  sort  of  cooking  process.  Two  hours  is  not 
infrequently  consumed  in  cooking  out  a  growth.  Butlin  strongly 
opposed  the  use  of  the  cautery  in  the  mouth,  believing  that  the  scar 
was  more  apt  to  be  the  site  of  a  return  of  the  cancer  than  was  the 
scar  of  a  clean  knife  excision.  Kocher,  however,  has  alwavs  pre- 
ferred to  cut  through  the  intraoral  tissues  with  a  cautery,  believing 
that  it  limited  septic  infection. 

The  writer's  own  experience  has  led  him  to  believe  that  there  are 
certain  very  distinct  advantages  in  the  use  of  the  low  heat  cautery 
and  that  in  the  past  two  years  he  has  secured  much  better  results  with 
the  cautery  than  he  formerly  did  with  knife  excisions  and  he  has  also 
been  able  to  operate  upon  cases  in  which  a  knife  excision  could  not 
have  been  made.  There  is  one  observation  we  have  made  in  removing 
carcinomata  of  the  mouth  by  "slow  cooking"  that  is  possibly  worth 
considering;  while  the  hot  cautery  probably,  as  Kocher  contends, 
reduces  sepsis,  the  low  heat  cautery  seems  to  materially  increase  the 
septic  infection  that  follows  the  operation.  With  the  use  of  the 
cautery,  after  having  completed  the  neck  dissection,  it  is  frequently 
possible  to  remove  a  limited  primary  intraoral  growth  without  any 
loss  of  blood  and  without  materially  adding  to  the  shock,  thus  ac- 
complishing at  one  sitting  what  has  been  considered  the  best  practice 
to  do  in  two  stages.  In  a  number  of  cases  in  which  this  has  been 
done  there  has  resulted  a  more  or  less  severe  infection  of  the  sub- 
maxillary part  of  the  neck  wound,  coming  on  several  days  later ;  this 
was  attributed  to  infection  traveling  down  the  lymphatics  from  the 
slough  in  the  mouth.     While  the  writer  has  always  had  a  theoretical 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES.  443 

objection  to  doing  the  neck  dissection  before  removing  the  primary 
growth,  he  now  feels  that  these  theoretical  objections  should  be  put 
aside.  It  is  better  to  do  the  neck  dissection  and  later,  when  the  neck 
has  healed,  remove  the  primary  growth  with  a  low  heat  cauter}-.  If 
the  growth  is  removed  first,  with  the  cautery,  there  is  usually  con- 
siderable reaction  in  the  nodes  and  this  may  interfere  with  the  healing 
of  the  neck  wound  when  the  dissection  is  made  within  a  week  or 
two.  For  very  limited  primary  growths  both  the  neck  dissection 
and  the  intraoral  excision  may  be  made  at  the  same  time,  but  Butlin's 
statistics  show,  in  an  indisputable  manner,  that  a  two-step  operation 
is  much  safer  than  doing  both  the  intraoral  and  the  neck  operation 
at  the  same  sitting. 

The  writer  has  come  to  believe  that  properly  applied  massive  doses 
of  x-ray  or  radium  are  good  postoperative  treatment  for  advanced 
carcinoma  of  the  mouth,  but  is  not  as  yet  willing  to  accept  the  latter 
form  of  treatment  as  a  substitute  for  radical  excision  in  operable  cases 
and  he  has  never  seen  one  inoperable  case  cured  either  by  radium 
or  x-ray.  X-ray  in  insufficient  dose  seems  to  stimulate  the  growth 
of  the  cancer. 

The  majority  of  tumors  occurring  in  or  about  the  mouth  are 
epithelial  and  after  middle  hfe  with  few  exceptions  these  are  malignant. 
While  some  of  the  connective  tissue  tumors  are  even  more  malignant 
than  the  carcinomata,  on  account  of  their  comparative  rarity  they 
are  of  less  compelling  interest.  Among  the  non-epithelial  tumors 
are  represented  almost  every  form  of  new-growth  with  the  exception 
of  essential  tumors  of  certain  special  tissues. 

Carcinoma  of  the  Mouth  is  usually  of  the  squamous  prickle- 
celled  variety  arising  from  the  mucous  membrane,  although  adenocarci- 
noma may  arise  from  related  glands,  and  basal-celled  tumors  do  occur. 
Even  in  the  antrum  and  nose,  ciliated  epithelium  is  replaced  by 
squamous  cells  before  cancer  develops. 

Carcinoma  of  the  mucous  membrane  develops  much  more  fre- 
quently in  men  than  in  women,  in  the  proportion  of  about  twelve  or 
fifteen  to  one.  It  is  a  disease  of  the  latter  half  of  life,  but  has 
occurred  in  children.  Pond  cites  a  case  of  epithelioma  of  the  palate 
in  a  boy  sixteen,  and  Hochenegg,  one  in  a  child  of  six  years. 

The  majority  of  all  cases  can  be  traced  to  leucoplakia  or  some 
local  irritation,  and  syphilis  is  supposed  to  be  a  strong  predisposing 
factor.  The  general  spread  of  syphilis  and  the  use  of  tobacco  in 
Europe  toward  the  end  of  the  middle  ages  are  credited  with  producing 
a  sudden  increase  in  the  occurrence  of  cancer  of  the  mouth.  Like 
cancer  elsewhere,  its  frequency  is  still  increasing.  Owing  to  their 
accessibility  and  the  sensitiveness  of  the  mouth,  the   whole  progress 


444  SURGERY  OF  THE  MOUTH  AND  JAWS. 

of  these  cancers  can  be  observed  better  than  in  any  other  location 
.except  the  skin.  Some  of  these  precancerous  lesions  exist  for  years, 
some  for  a  few  months.  The  actual  cancers  themselves  as  a  rule  are 
rather  indolent  at  first.  The  indolent  stage  may  exist  for  a  long 
time,  even  years ;  this  is  especially  true  of  cancers  of  the  lip.  A  fewer 
number  show  rapid  growth  from  the  first,  and  the  lymph  nodes  have 
been  known  to  become  infected  within  three  weeks  after  the  appear- 
ance of  the  initial  lesion.  A  peculiarity  of  the  disease  in  this  location 
is  that  though  it  always  will  in  time  infect  the  lymphatics  of  the  neck 
and  in  some  instances  very  early,  in  but  one  per  cent  of  the  cases 
does  it  cause  distant  or  general  metastases.  Even  when  the  neck 
glands  are  extensively  involved,  it  is  often  curable,  and  apparent 
fixation  of  these  nodes  does  not  necessarily  mean  that  they  are  in- 
operable, as  it  is  only  late  that  they  become  fixed  to  the  spine  and 
the  carotid  artery.  Removal  of  all  structures  of  one  side,  with  the 
exception  of  the  internal  and  common  carotid  arteries,  is  not  incom- 
patible with  life.  In  an  old  person  with  sclerotic  arteries,  tying  the 
internal  or  common  carotid  arteries  is  equivalent  to  a  death  warrant 
(Kocher). 

The  virulence  of  cancer  of  the  mouth  varies  in  different  loca- 
tions ;  and  as  a  general  rule  the  operation  becomes  more  serious  the 
further  back  in  the  mouth  the  growth  occurs. 

The  treatment  formerly  was  always  with  escharotics  or  by  re- 
moval, but  recently  Roentgen  rays  or  radium  have  been  used. 
With  perfected  technique  radical  excision  with  or  without  the  aid 
of  the  actual  cautery  is  the  one  means  that  holds  out  promise  for 
advanced  cancer;  and  from  very  poor  beginnings  this  method  has 
now  reached  a  stage  of  substantial  achievement  and  with  far  greater 
promise  for  the  future. 

Except  in  a  comparatively  few  very  virulent  tumors,  the  two 
causes  of  poor  results  are  incomplete  operation  and  late  treatment. 
It  is  difficult  to  conceive  of  more  radical  operations  than  are  now 
being  practiced,  but  in  regard  to  the  average  time  at  which  the  dis- 
ease is  brought  to  treatment  there  is  much  room  for  improvement. 
That  this  unfortunate  state  of  affairs  is  through  educational  efforts 
being  radically  improved  will  be  shown  in  the  study  of  the  history 
of  statistics  of  cancer  in  various  geographical  localities.  From  these 
it  would  seem  not  improbable  that  at  no  distant  time  the  percent- 
age of  cures  for  cancer  of  the  mouth,  with  the  possible  exception  of 
those  arising  in  the  upper  jaw,  will  be  as  high  as  for  any  other 
part  of  the  body. 

The  following  data  are  obtained  from  a  series  of  forty-six  re- 
ferred private  cases  of  cancer  of  the  mouth  coming  under  observa- 


TU^IORS  OF  THE  MOUTH  AND  JAW-BONES. 


445 


tion  between  January  1,  1912,  and  June  1,  1916,  and  of  four  cases 
which  came' to  the  writer's  service  at  the  Barnes  Hospital  during 
the  same  period.  The  cases  seen  in  the  out-service  department  of 
the  Washington  University  clinic  are  not  included,  as  the  writer 
wished  to  draw  conclusions  as  to  the  present  status  of  treatment  of 
the  class  who  consult  their  own  private  physician  or  dentist.  Most 
of  these  cases  came  from  within  an  area  of  100  miles  of  St.  Louis. 

Fifty  Cases  of  Cancer  of  the  Mouth  Between  Jan.  1,  1912  and 

June  1,  191G. 


No. 

InoperaDle 

Par 
Advanced 

Medium 

Early 

Lower    Lip 

One    Cheek 

Both    Cheeks....... 

Upper    Jaw 

11 

8 
1 
3 
1 
8 
3 
13 
2 

3 

1 

o 
3 

2 
2 

2 

4 

1 

4 
1 

7 

6 
2 

1 
1 
2 

1 
1 

Palate 

Lower    Jaw 

Floor 

1 
1 

Tongue 

2 

Tonsil 

When  these  cases  came  under  the  observation  of  the  writer,  only 
13  per  cent  were  in  the  early  stage,  while  38  per  cent  were  far  ad- 
vanced and  26  per  cent  were  frankly  inoperable.  The  remaining  24 
per  cent  might  be  classed  as  medium,  that  is  to  say,  there  was  dis- 
tinct cancer  infiltration  surrounding  an  ulcerated  area  with  palpable 
involvement  of  the  regional  glands.  Early  designates  a  precancer- 
ous lesion  or  a  lesion  in  which  demonstrable  infiltration  of  the  cells 
has  not  yet  occurred.  All  but  one  of  them  were  scj^uamous  epithelial 
tumors.  '  • 

From  the  histories  it  was  evident  that  each  of  the  growths  had 
existed  in  a  form  that  should  have  excited  at  least  the  suspicion  of 
a  carcinoma  for  periods  varying  from  two  weeks  to  thirty-six  months 
before  coming  under  the  writer's  observation.  This  survey  was 
undertaken  with  the  idea  of  getting  a  line  on  the  kind  of  advice  that 
was  given  to  the  ordinary  citizen  when  he  consulted  his  own  phy- 
sician or  dentist  for  a  lesion  of  this  kind.  An  interesting  incidental 
deduction  was  made  regarding  the  malignancy  of  these  growths. 
While  the  three-year-old  case  was  an  inoperable  cancer  of  the 
tongue  that  had  probably  been  held  in  abeyance  by  radium,  still 
there  is  not  the  general  relation  between  the  stage  of  advancement 
and  the  age  of  the  growth  that  one  might  except.    One  cancer  of  the 


446  SURGERY  OF  THE  MOUTH  AND  JAWS. 

lip  that  had  existed  for  three  years  was  of  only  medium  advance- 
ment, and  one  of  the  base  of  the  tongue  was  probably  still  operable 
at  two  and  one-half  3^ears  after  it  first  gave  symptoms.  Of  eleven 
cancers  of  the  lip,  six  were  apparently  very  limited  after  an  average 
time  of  sixteen  months,  but  of  those  that  were  inoperable,  one  had 
been  present  for  one  year  only  and  one  for  but  three  months.  The 
writer  saw  one  cancer  of  the  lip  in  the  out-patient  department  of 
Washington  University  which  was  apparently  operable  after  seven- 
teen years,  but  it  was  probably  a  basal-celled  tumor.  The  .only  one 
of  the  six  medium  grade  lip  tumors  known  to  have  had  a  return, 
after  radical  operation,  had  been  present  but  six  months.  The  same 
variation  is  found  in  the  tumors  within  the  mouth.  While  several 
tumors  of  the  lower  jaw  and  tongue  were  apparently  within  the 
limit  of  operability  after  a  year  and  a  half,  and  one  of  the  base  after 
two  and  one-half  years,  another  of  the  base  of  the  tongue  was  in- 
operable six  weeks  after  the  first  symptoms,  one  of  the  lower  jaw 
four  weeks  after  it  was  first  noticed  and  one  of  the  cheek  was  at  the 
extreme  limit  of  surgical  intervention  three  weeks  after  it  was  first 
detected.  From  this  it  is  evident  that,  to  the  two  factors  usually 
considered  in  the  curability  of  cancers,  that  is,  the  time  at  which 
treatment  is  instituted  and  the  character  of  the  operation,  we  must 
add  a  third,  viz.,  the  virulence  of  the  growth,  even  though  it  is 
probable  that  the  time  of  the  presence  of  some  of  the  quick  growing 
tumors  was  much  longer  than  noted. 

Precancerous  Lesions. — In  most  of  these  there  was  present, 
probably  for  some  time  before  actual  cancer  developed,  a  lesion  that 
is  known  to  predispose  to  such  a  growth.  In  one  case  there  had 
been  a  chronic  fissure  of  the  lip  for  twenty-five  years  and  leuco- 
plakia,  the  most  common  antecedent,  is  often  present  for  many 
years  before  cancerous  change  occurs.  Cancer  of  the  lip  is  not  in- 
frequently preceded  by  an  injury  or  a  herpes. 

Radical  Operation. — In  thirty-two  cases  which  included  the 
medium  grade,  the  far  advanced,  and  the  inoperable,  radical  cures 
were  done  or  attempted  by  one  or  several  operations ;  five  being 
the  most  done  on  one  patient  before  all  tissues  likely  to  l)e  infected 
were  removed  and  repair  afifected.  In  all,  fifty-three  operations 
were  done  upon  these  thirty-two  patients.  Of  the  thirty-two  cases, 
seven  died  while  in  the  hospital,  an  operative  death-rate  of  21  per 
cent,  which  although  too  high,  but  partially  reflects  the  ordinary 
mortality  for  desperate  cases. 

A  perusal  of  the  causes  of  death  is  one  of  interest : 

Two  cases  of  jaw  resection  died  of  secondary  hemorrhage,  one  fifteen 
days  and  one  thirty  days  after  operation. 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES.  447 

Two  of  pneumonia,  one  of  these  ninety  days  after  the  third  operation 
but  while  in  the  hospital.  The  other,  a  steady  drinker,  seventy-five  years 
of  age,  died  two  weeks  after  complete  resection  of  the  submental,  two  sub- 
maxillary, and  one  deep  and  superficial  cervical   regions  at  one  operation. 

One  of  gangrene  of  the  intestine,  from  arteriosclerosis  sixty-eight 
days  after  the  second  operation. 

One  of  erysipelas  two  weeks  after  a  gland  operation. 

One  twelve  hours  after  operation  from  an  unrecognized  thrombosis  of 
the  coronary  artery,  after  resection  of  the  lower  jaw,  tongue,  pharynx  and 
glands  at  one  operation.  This  was  a  man  seventy-five  years  of  age  and 
the  only  one  of  the  series  to  die  within  two  weeks. 

Local  Operation. — In  the  six  early  cases  there  was  no  operative 
death,  nor  would  there  in  any  probability  have  been  a  death  in  five 
hundred  or  a  thousand  such  operations  and  the  chance  of  permanent 
cure  is  inverse  to  the  operative  risk.  This  brings  the  writer  to  the 
chief  point  that  he  wishes  to  consider. 

Of  the  fifty  cases,  four  were  far  advanced  and  three  were  inoper- 
able within  two  months  after  they  had  attracted  the  patient's  atten- 
tion. These  probably  represent  a  type  of  cancer  over  which  we 
have  little  control.  To  begin  with,  therefore,  we  have  16  per  cent 
in  this  series  that  are  probably  incurable  by  present  methods, 
though  education  and  good  surgery  might  have  saved  some  of  these. 
Four-sevenths  of  the  remaining  84  per  cent  came  to  operation  six 
months  or  longer  after  they  should  have  been  diagnosed,  and  many 
had  been  under  "medical"  treatment  for  months. 

One  of  the  lip  cancers  came  to  operation  after  one  year  and  a 
half,  another  after  two  years  and  another  after  three  years  duration; 
the  average  time  at  which  these  lip  cases  came  to  operation  was 
thirteen  months  after  they  were  plainly  cancerous. 

Of  the  jaw,  tongue,  and  cheek  cancers,  four  were  of  one  year's 
duration  and  two  were  of  one  and  a  half  year's  standing  when  they 
were  operated  upon,  yet  all  of  the  foregoing  cases  were  operated 
upon  with  some  chance  of  cure.  One  apparently  operable  tongue 
case  refused  operation  two  and  one-half  years  after  the  first  symp- 
tom. 

The  crux  of  the  situation  in  the  84  per  cent  of  cases  in  this 
series  is  early  diagnosis.  The  majority  of  them  could  and  should 
have  been  recognized  at  a  time  when  the  operative  death  rate  should 
be  almost  nil  and  the  cures  at  least  around  70  per  cent.  As  it  is, 
in  this  series,  only  six  of  the  intraoral  could  meet  these  require- 
ments. 

In  every  series  of  observations  of  cancers  of  the  mouth  an  im- 
provement in  this  regard  has  been  noticed  in  recent  years  and  this 
is  true  in  the  series  here  presented.    Dividing  the  period  of  observa- 


448  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tion  in  two,  there  were  nineteen  cases  in  the  first  twenty-seven 
months  and  thirty-one  in  the  second  twenty-seven  months.  In  the  first 
nineteen  cases  there  was  one  early  case,  or  5+per  cent ;  in  the  latter 
thirty-one  there  were  six  early  cases,  or  19+per  cent.  This  is  the 
only  improvement.  The  proportion  of  advanced  and  inoperable 
cases  was  about  the  same  in  both  halves  of  the  whole  series. 

Of  twenty-six  medium  grade,  advanced  and  inoperable  cancers 
that  were  observed  during  the  latter  twenty-seven  months  ,i.  e.,  be- 
tween April,  1914  and  June,  1916,  sixteen  or  61  per  cent,  are  known 
to  have  been  under  the  observation  of  a  doctor  or  a  dentist  for 
periods  varying  from  weeks  to  over  a  year  before  the  diagnosis  was 
established,  but  from  the  histories  subsequently  obtained  it  is  evi- 
dent that  in  every  one  of  these  cases  there  were  sufficient  data 
present  at  the  time  of  the  first  examination  to  render  the  diagnosis 
of  cancer  at  least  strongly  presumptive.  In  only  three  of  the  six- 
teen cases  was  a  microscopical  diagnosis  attempted,  and  in  these,  un- 
fortunately, the  pathologist's  report  was  misleading. 

There  are  a  number  of  other  interesting  but  less  important 
points  that  are  suggested  by  a  study  of  this  series.  The  first  is,  that 
with  rare  exception  the  history  and  gross  physical  characteristics 
are  sufficient  data  upon  which  to  base  a  diagnosis  from  the  very 
early  stages  of  the  growth  and  that  microscopical  findings,  unless 
cautiously  interpreted,  may  be  fatally  misleading.  In  three  of  the 
cases  operation  was  delayed  from  nine  to  eighteen  months  because 
the  microscopical  findings  were  reported  negative.  One  of  these  pa- 
tients died  after  three  extensive  operations ;  one  had  an  inoperable 
recurrence  after  five  operations  and  the  other  one  had  but  a  doubt- 
ful chance  of  a  permanent  cure.  The  physician  should  not  be  mis- 
led by  the  report  "does  not  show  carcinoma,"  interpreting  it  to 
mean  "is  not  carcinomatous;"  this  has  been  the  cause  of  the  fatal 
mistakes  cited. 

The  practice  of  removing  a  piece  of  a  mouth  ulcer  for  micro- 
scopical examination  is  in  itself  not  free  from  danger  of  disseminating 
the  disease.  If  the  growth  or  ulcer  is  sufficiently  doubtful  in  its 
character  to  require  a  microscopical  examination,  then  the  whole 
growth  or  ulcer  should  be  removed  with  a  fair  margin;  in  this  way 
the  danger  of  fatal  damage  to  the  patient  is  avoided  and  the  chances 
of  a  correct  microscopical  diagnosis  greatly  increased.  If  the  whole 
growth  or  ulcer  cannot  be  removed,  then  the  section  should  be  taken 
with  an  electric  cautery,  a  portion  of  healthy  tissue  at  the  base  and 
at  the  edge  being  included.  Bloodgood  has  found,  in  the  lip  cancers 
coming  to  his  notice,  that  in  those  in  which  there  has  been  no 
previous  treatment  or  section,  the  nodes  were  demonstrably  cancer- 


TUAIORS  OF  THE  MOUTH  AND  JAW-BONES.  449 

ous  in  ZJ  per  cent,  but  in  those  where  there  had  been  partial  sec- 
tion or  inadequate  treatment  of  any  kind,  the  nodes  were  demon- 
strably cancerous  in  60  per  cent. 

Use  of  Local  Irritants. — The  next  point  is  the  evil  effects  of  the 
use  of  irritants  upon  cancerous  growths.  The  most  pernicious  and 
prevalent  one  is  the  use  of  silver  nitrate  in  applications  insufficient 
to  absolutely  destroy  the  growth.  Several  of  these  histories  show 
that  after  such  treatment  rather  indolent  carcinomatous  growths 
have  been  stimulated  into  most  virulent  activity.  One  lip  cancer, 
under  this  treatment,  was  inoperable  three  months  after  the  first  ap- 
pearance of  the  ulcer,  and  another  one  was  inoperable  at  one  year ;  yet 
the  average  duration  before  our  lip  cases  came  to  operation  has  been 
thirteen  months. 

Delayed  Infection  of  Neck  Glands. — Attention  is  called  to  a  brief 
series  of  four  cases  of  recurrence  in  the  nodes  of  the  neck  after  cure 
of  the  primary  ulcer  of  the  lip  : 

The  first  case  was  that  of  a  doctor  who  reported  that  one  year  after  a 
successful  removal  of  a  carcinomatous  ulcer  from  his  lip,  he  called  his 
surgeon's  attention  to  an  enlarged  submaxillary  node  and  was  told,  by  the 
surgeon,  to  "forget  it."  He  presented  himself  four  months  after  the  al- 
leged conversation  and  had  a  stinking  ulcer  that  extended  from  the  open 
floor  of  the  mouth  to  within  an  inch  of  the  clavicle. 

The  second  case  was  that  of  a  man  from  whom  the  writer  removed  a 
mass  of  submaxillary  lymph  nodes  infected  -with  squamous-celled  car- 
cinoma, which  appeared  eight  years  after  he  had  a  chronic  lip  ulcer  cured 
with  a  paste;  the  ulcer  had  not  returned. 

A  similar  case  was  seen  in  the  out-patient  department  of  the  Washing- 
ton University  clinic,  the  nodes  enlarging  three  years  after  the  cure  of 
the  ulcer. 

The  fourth  in  the  series  was  a  squamous  carcinoma  removed  from  the 
submaxillary  nodes  in  a  woman  who,  during  a  period  of  two  years,  had  a 
lip  ulcer  that  cured  without  treatment  three  years  before  the  submaxillary 
lump  appeared.  This  case  was  unique,  being  the  only  recorded  one  of  a 
spontaneous  cure  of  a  presumable  lip  carcinoma. 

All  of  the  foregoing  has  been  given  chiefly  to  emphasize  the 
fact  that  carcinoma  of  the  inside  of  the  mouth,  now  generally  re- 
garded as  one  of  the  most  hopeless  forms  of  the  disease,  is  hopeless 
chiefly  on  account  of  largely  avoidable  procrastination  and  partly 
on  account  of  pernicious  treatment.  The  mouth  is  one  of  the  most 
sensative  and  one  of  the  most  easil}^  observed  cavities  in  the  body. 
When  the  public  is  taught  the  advisability  of  consulting  a  physician 
or  a  dentist  in  regard  to  every  localized  thickening,  discoloration, 
crack  or  ulceration  that  appears  within  the  mouth  and  which  per- 
sists for  more  than  a  few  days ;  when  the  physician  or  dentist  con- 
sulted will  bend  his  efiforts  toward  making  an  accurate  diagnosis 


450  SURGERY  OF  THE  MOUTH  AND  JAWS. 

rather  than  dismissing  it  as  inconsequential  or  tentatively  using 
various  irritants  in  an  attempt  to  cure  it;  when  patients  of  cancer 
age  with  leucoplakia  or  other  chronic  epithelial  change  are  warned 
of  the  danger  of  cancerous  degeneration  and  of  the  frequently  in- 
sidious nature  of  the  onset  of  the  change;  when  surgeons  operating 
upon  mouth  carcinoma  will  make  sufficiently  wide  local  excisions 
and  extensive  painstaking  regional  lymphatic  dissections,  not  cur- 
tailing the  latter  because  the  cancer  is  early,  but  rather  making  the 
dissection  thorough  in  the  early  case  on  account  of  the  greater 
chance  of  curing  these  early  cases ;  then,  and  only  then,  will 
results  of  operation  for  cancer  of  the  inside  of  the  mouth  compare 
favorably  with  the  results  obtained  in  other  regions. 

RETROMAXILLARY  TUMORS. 

A  number  of  tumors  growing  or  originating  within  the  spheno- 
maxillary fossa  may  come  under  this  heading.  The  most  common  is 
the  fibrous  tumor,  which  arises  from  the  base  of  the  skull  in  the  form 
of  the  nasopharyngeal  polyp,  which,  as  it  grows,  fills  the  nasal  fossa 
and  the  nasopharynx  and  extends  through  the  sphenopalatine  foramen 
into  the  sphenomaxillary  fossa,  thence  along  the  line  of  least  resistance, 
filling  the  posterior  part  of  the  orbit  and  the  zygomatic  fossa.  It  may 
enter  the  antrum  and  fill  this  also.  As  the  tumor  grows,  it  forms 
adhesions,  and  it  is  these  new  attachments  that  render  the  growths 
very  difficult  of  radical  removal.  They  occur  almost  exclusively  in 
young  males,  first  appearing  about  puberty,  and  continuing  to  grow 
until  they  reach  the  age  of  about  eighteen  or  twenty  years,  when 
growth  usually  ceases,  or  the  tumor  may  recede.  Occurring  as  they 
do  during  the  period  of  body  growth,  it  is  easily  understood  how  they 
cause  deformity  of  the  bones  which  bound  the  cavities  they  invade. 
The  nose  becomes  broad,  the  eyeball  protrudes,  the  cheek  bones  become 
prominent,  and  the  zygoma  is  bowed  outward.  The  faucial  pillars  may 
be  pushed  downward  and  inward,  and  a  red,  soft,  easily  bleeding  mass 
protrudes  from  the  nose,  while  the  entire  naso-  and  oropharynx  may 
be  filled  with  the  mass  to  such  an  extent  that  tracheotomy  is  required. 
According  to  Schlatter,  the  alveolar  arch  and  hard  palate  are  not  in- 
volved in  the  non-malignant  growths.  In  a  case  of  ours,  however, 
which  was  subjected  to  repeated  and  careful  examinations  by  Dr.  Opie, 
and  Drs.  Smith  and  McBain  of  his  staf¥,  and  was  pronounced  by  them 
to  be  pure  fibroma,  there  was  destruction  of  the  hard  palate  by  a  mass 
of  the  tumor  which  protruded  through  the  bone.  The  roots  of  several 
molar  teeth  were  loose  and  painful,  and  particles  of  the  tumor  were 
adherent  when  they  were  removed. 

Besides  a  microscopical  examination,   the  diagnosis  between  the 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES.  451 

pure  fibromata  and  malignant  tumors  is  to  be  made  on  the  history  and 
the  behavior  of  the  growth.  The  nasopharyngeal  fibroma,  or  polyp, 
begins  with  a  growth  in  the  nasopharynx  or  the  sphenomaxillary  fossa, 
causing  partial  obstruction.  If  the  growth  is  higher,  near  the  sphe- 
noidal fissure,  there  may  be  ptosis,  palsy  of  the  ocular  muscles,  choked 
disc,  and  impairment  of  vision.  As  the  tumor  gradually  enlarges,  the 
clinical  picture,  already  described,  develops,  but  it  takes  some  years  to 
do  so.  The  bones  become  distorted,  but  usually  not  thinned.  Truly 
malignant  tumors,  as  a  rule,  grow  rapidly  and  destroy  the  bones  they 
encounter;  but  the  dividing  line  between  certain  fibromata  and  the 
fibrosarcomata  is  difficult  to  establish. 

The  prognosis  of  the  frankly  malignant  tumor  is  bad,  but  in  a  few 
sarcomata  something  might  be  accomplished  by  the  use  of  toxins  or  the 
ligation  of  vessels. 

The  prognosis  of  the  pure  fibromata  is  not  always  good ;  as  many 
of  them  cease  to  grow  or  even  shrink  with  the  cessation  of  normal  body 
growth,  and  as  much  can  be  accomplished  by  carefully  planned  surgery, 
the  prognosis  of  these  tumors  is  not  nearly  so  bad  as  the  extent  of  the 
involvement  might  lead  one  to  think. 

Treatment  of  Retromaxillary  Fibromata. — ^Von  Langenbeck  did 
a  temporary  resection  of  the  maxilla,  and  removing  the  tumor,  cauter- 
ized the  base  with  the  actual  cautery.  Partly  on  account  of  hemorrhage, 
this  is  a  most  dangerous  procedure.  Considering  the  tendency  of  the 
tumor  to  spontaneous  subsidence  at  the  end  of  adolescence,  it  is  hardly 
warranted,  but  the  hemorrhage  in  all  such  operations  can,  to  a  certain 
extent,  be  controlled  by  a  temporary  ligation  of  both  external  carotids. 
It  is  better  to  remove  the  tumor  piecemeal  at  different  operations,  in 
hope  of  holding  it  in  control  until  it  ceases  to  grow.  If  its  pharyngeal 
attachment  can  be  determined,  this  part  can  be  removed  with  a  strong 
snare  or  old-fashioned  uterine  ecraseur.  Before  this  is  attempted,  a 
postnasal  tampon  should  be  prepared.  Its  strings  should  be  in  place 
in  the  nose  before  the  base  of  the  tumor  is  cut,  so  that  the  tampon  can 
be  immediately  drawn  into  place.  The  tampon  must  be  of  the  proper 
size,  and  the  strings  must  be  strong,  as  must  be  the  wire  of  the  snare. 
An  accident  to  any  of  these,  after  the  base  is  partially  or  wholly  cut, 
might  lead  to  disastrous  hemorrhage. 

The  zygomatic  and  temporal  fossae  can  be  invaded  by  a  properly 
placed  incision  and  a  temporary  resection  of  the  zygoma ;  the  orbit,  by 
a  temporary  resection  of  the  malar  bone.  But  in  operating,  the  incision 
should  be  so  planned  as  not  to  cut  the  branch  of  the  seventh  nerve  that 
supplies  the  eyelid.  The  maxillary  sinus  can  be  opened  by  the  Denker 
operation  (see  p.  423).    The  cutting  off  of  the  blood  supply,  after  the 


452  SURGERY  OF  THE  MOUTH  AND  JAWS. 

method  of  Dawbarn,  and  the  use  of  Coley's  toxins  are  also  to  be  con- 
sidered. 

A  report  of  the  following  case  will,  we  believe,  be  of  interest : 
A  boy,  twenty  years  of  age,  from  whom  a  nasopharyngeal  polypus  had 
been  repeatedly  removed  from  the  nasopharynx  between  the  ages  of  sixteen 
and  nineteen  years,  was  finally  given  up  as  hopeless,  and  he  came  to  us  for 
tracheotomy.  Examination  showed  a  red,  soft  growth,  protruding  1  centi- 
meter from  the  right  nostril — the  nasal  fossa  was  greatly  expanded  on  that 
side  and  collapsed  on  the  other.  The  cheek  was  prominent,  as  was  the 
zygoma,  and  there  was  a  well-marked  exophthalmos,  without  ocular  symp- 
toms. The  whole  of  the  nasopharynx  and  oropharynx,  as  far  as  the  finger 
could  reach,  was  filled  with  a  rather  firm  tumor  which  had  its  attachment 
above.  In  April,  1911,  tracheotomy  was  done.  A  week  later  the  branches 
of  the  right  external  carotid  were  exposed,  and  the  superior  thyroid,  lingual, 
facial,  ascending  pharyngeal,  and  occipital  arteries  were  doubly  ligated. 
The  remaining  part  of  the  vessel,  that  giving  off  the  posterior  auricular, 
temporal,  and  internal  maxillary  arteries,  was  injected  first  with  boiling 
water,  but  as  this  did  not  stop  the  recurrent  flow  of  blood,  the  vessels  were 
injected  with  6  cubic  centimeters  of  hot  wax.  After  this,  the  wax  could  be 
felt  in  the  temporal  artery.  One  week  later,  this  operation  was  repeated 
upon  the  left  side,  and  after  splitting  the  velum,  the  pharyngeal  portion  of 
the  growth  was  removed,  the  strings  of  the  postnasal  tampon  having  been 
previously  placed  in  the  nose.  After  splitting  the  velum,  it  was  found  that 
both  the  nasal  and  pharyngeal  parts  of  the  tumor  arose  from  a  broad  base 
attached  around  the  neighborhood  of  the  sphenopalatine  foramen  and  to 
the  outer  wall  of  the  nasal  fossa.  With  a  proper  snare  the  whole  mass 
could  have  been  removed  at  this  time,  as  the  nostril  was  so  distended  as  to 
easily  admit  the  index  finger  for  its  full  length;  but  there  was  none  at  hand, 
the  strength  of  which  we  were  willing  to  trust.  The  free  hemorrhage,  which 
occurred  after  attempting  to  crush  the  base  with  a  long  clamp,  convinced 
us  that  the  growth  obtained  some  of  its  blood  supply  from  the  branches  of 
the  internal  carotid.  Consequently,  after  also  removing  a  large  part  of  the 
mass  from  the  anterior  nares,  the  anterior  and  postnasal  tampons  were 
drawn  into  place.  Two  weeks  later,  it  was  found  that  the  growth  in  the 
temporal  fossa  had  receded  so  that  it  could  no  longer  be  felt,  but  of  course, 
the  zygomatic  arch  was  still  prominent.  We  believe  the  recession  of  this 
part  of  the  growth  was  caused  by  the  shutting  off  of  its  blood  supply.  The 
part  of  the  tumor  in  the  nasal  fossa  continued  to  grow  rapidly,  and  by  this 
time  again  protruded  1  centimeter  from  the  nostril.  The  injection  of 
Coley's  toxin  was  begun,  giving  at  first  J^  drop  and  gradually  increasing 
the  dose  to  5  drops  each  day.  The  injections  were  given  in  the  arm,  and 
no  general  reaction  was  ever  noticed.  In  about  two  weeks  afterward,  he 
noticed  he  could  draw  breath  through  the  left  nostril,  and  in  the  course  of 
a  month,  he  could  draw  breath  through  the  right  nostril.  During  this  time, 
without  any  other  treatment,  the  nasal  growth  had  shrunk  until  the  anterior 
nares  appeared  almost  empty,  its  lateral  attachment  being  represented  by 
a  red  scar. 

The  toxins  were  continued  for  four  months,  at  which  time  they  were 


TUMORS  OF  THE  MOUTH  AND  JAW-BONES.  453 

discontinued  because  the  boy  was  anemic  and  depressed.  At  this  time  it 
was  found  that  the  whole  palpable  part  of  the  tumor  had  turned  into  a 
cavernous  angioma  with  thick  walls.  Several  injections  with  boiling  water 
had  little  effect,  but  much  of  it  was  later  destroyed  by  puncture  with  a  cau- 
tery.    At  the  present  time,  June,  1912,  the  tumor  is  growing  slowly. 

Tumors  of  the  septum,  tongue,  floor  of  the  mouth,  and  pharynx  will 
be  presented  in  separate  chapters. 


CHAPTER  XXXI. 

EXCISIONS  AND  TEMPORARY  RESECTIONS  OF  THE 

JAW-BONES. 

In  making  an  excision  of  any  part  of  the  jaw-bones,  conservatism 
is  to  be  strongly  recommended.  In  dealing  with  a  doubtful  tumor  of 
the  breast  or  of  almost  any  other  part  of  the  body,  the  surgeon  treats 
it  as  a  malignant  disease  and  makes  the  widest  possible  excision.  This 
is  not  the  rule  by  which  he  should  be  guided  when  confronted  with  a 
tumor  of  the  jaw.  Partly  on  account  of  the  deformity  resulting  from 
an  extensive  excision,  partly  because  extensive  resections  are  more  apt 
to  be  fatal,  but  chiefly  because  benign,  mildly  malignant,  and  small 
malignant  tumors  are  best  treated  by  limited  excisions,  and  the  very 
malignant  ones  can  seldom  be  cured  by  any  reasonable  surgical  pro- 
cedure, surgeons  are  coming  to  the  conclusion  that  in  the  jaws  the  rule 
should  be  reversed,  and  doubtful  tumors  should  be  treated  by  limited 
excisions. 

RESECTIONS  AND  EXCISIONS  OF  THE  MAXILLA. 

In  the  upper  jaw,  owing  to  the  softness  of  the  bone  and  its  solid 
attachments,  the  alveolar  process,  the  hard  palate,  and  in  fact  the  whole 
bone  can  be  removed  with  a  chisel.  In  the  lower  jaw  the  alveolar 
process  can  be  removed  with  biting  forceps,  but  if  the  excision  is  to 
extend  into  the  substance  of  the  body,  it  is  best  accomplished  with  a 
wire  saw. 

Resection  of  the  Superior  Alveolar  Process. — To  remove  an  ex- 
tensive section  of  the  upper  alveolus,  a  tooth  is  drawn  in  front  of  and 
behind  the  section  to  be  removed.  The  mucoperiosteal  covering  along 
the  line  of  junction  of  the  palate  and  alveolar  process  is  cut  between 
these  points.  A  corresponding  incision  may  be  made  along  the  outer 
covering  of  the  bone ;  but  this  is  not  necessary,  as  here  the  mucosa  will 
be  cut  with  a  sharp  chisel.  At  the  extremities  of  the  proposed  excision, 
the  alveolar  process  is  cut  through  by  placing  the  edge  of  a  thin,  sharp 
chisel  across  its  lower  border  and  cutting  directly  upward.  These  two 
vertical  cuts  having  been  made,  the  chisel  is  placed  against  the  upper 
part  of  the  outer  surface  of  the  block  to  be  excised,  and  the  horizontal 
cut  is  made  (Fig.  37(!).  As  soon  as  the  block  is  felt  to  be  loose,  it  is 
grasped  with  toothed  forceps  and  twisted  out.     The  operation  is  very 

454 


EXCISIONS  OF  THE  JAW-BONES. 


455 


bloody,  but  can  be  completed  in  a  few  minutes,  when  the  hemorrhage 
is  controlled  .first  with  pressure  and  later  by  suturing  the  mucosa  of 
the  buccal  fornix  to  the  cut  edge  of  the  palate  mucosa.  If  the  surgeon 
prefers,  he  can  resect  the  upper  alveolus  with  a  wire  saw,  by  the  same 
procedure  as  is  described  for  resection  of  the  lower  alveolar  process. 

Resection  of  the  Palate  and  Alveolar  Process. — Removal  of  one 
half  of  the  alveolar  process  and  the  hard  palate  of  the  same  side  can  be 
done  as  follows : 

The  mucous  membrane  in  the  upper  fornix  is  to  be  incised  to  the 
bone.  If  the  mucoperiosteal  covering  of  the  palate  is  to  be  removed 
with  the  bone,  the  velum  of  that  side  is  detached  from  the  hard  palate 
by  a  transverse  incison  which  extends  from  the  midline  outward  between 
the  maxillary  tubercle  and  hamular  process.  This  cut  divides  the  full 
thickness  of  the  soft  palate,  and  the  bleeding  is  temporarily  checked  by 


Fig.  376.  Showing  the  line  of  the  bone  cuts  for  excision  of  one  half  of  the  upper 
alveolar  process.  Also  showing  the  line  of  the  bone  cuts  for  a  suprapalatal  excision  of 
the  maxilla. 


stuffing  a  wad  of  gauze  into  the  gap.  If  the  mucoperiosteal  covering 
of  the  palate  can  be  preserved,  it  is  incised  along  its  outer  border  and 
dissected  up  toward  the  midline.  The  velum  is  detached  from  the  pos- 
terior border  of  the  palate  process  by  cutting  through  the  palate 
aponeurosis  and  nasal  mucous  membrane  only.  In  this  way  the  velum 
remains  attached  to  the  soft  covering  of  the  hard  palate,  as  in  an  oper- 
ation for  cleft  palate.  If  the  growth  extends  on  the  buccal  mucosa, 
the  cheek  is  split,  and  the  growth  is  dissected  free  from  the  cheek  but 
left  attached  to  the  alveolar  process.  The  bone  excision  is  made  with 
two  cuts,  as  follows  : 

(A)  The  chisel  is  placed  vertically  against  the  anterior  surface  of  the 
alveolar  process  in  the  midline  and  driven  back  through  the  palate  to  its 
posterior  border.  In  doing  this,  it  is  not  necessary  to  drive  the  chisel 
to  its  full  thickness  through  the  alveolar  process  in  order  to  cut  the 
palate.     The  instrument  may  be  withdrawn  when  the  alveolus  is  cut 


456  SURGERY  OF  THE  MOUTH  AND  JAWS. 

through,  and  applied  to  the  palate  from  within  the  mouth.  If  the  cov- 
ering of  the  palate  is  to  be  preserved,  it  is  lifted  from  the  bone  with  a 
retractor.  If  it  is  to  be  included  in  the  excision,  it  is  cut  by  the  chisel 
along  with  the  bone. 

(B)  The  alveolar  process  and  palate  having  been  split,  the  chisel 
is  placed  against  the  front  of  the  jaw,  with  its  edge  and  long  axis 
parallel  to  the  palate.  The  chisel  is  driven  straight  back  to  the  level 
of  the  maxillary  tubercle,  and  then  by  depressing  the  handle  the  mass 
is  fractured  from  its  posterior  attachment.  If  this  cut  fails  to  loosen 
the  bone,  the  chisel  is  withdrawn,  and  its  edge  placed  against  the  malar 
process  of  the  maxilla.  This  can  be  felt  as  a  narrow  buttress  above 
the  first  molar  tooth.  This  is  cut  through  obliquely  upward  and  in- 
ward (Fig.  376). 

If  the  bone  has  been  weakened  by  the  disease,  it  is  better  to  cut  the 
maxilla  from  the  pterygoid  process  with  a  chisel  than  to  attempt  to 
break  it  at  this  point;  the  fracture  might  occur  through  the  diseased 
part. 

If  the  excision  is  to  include  more  than  half  of  the  lower  part  of  the 
maxilla,  the  nasal  septum  will  have  to  be  cut  through.  This  can  be 
done  by  placing  the  chisel  against  the  anterior  nasal  spine  of  the 
maxillae  and  cutting  straight  back  for  the  full  length  of  the  septum. 
This  should  be  done  before  the  body  of  the  maxilla  is  cut  through.  By 
dissecting  up  the  tissues  of  the  face,  the  whole  of  the  maxilla  below  the 
orbital  plate  can  be  removed  with  a  chisel.  In  its  upper  part  the  body 
is  so  broad  that  two  transverse  cuts  will  be  required,  one  for  the  outer 
wall  of  the  nasal  fossa,  and  one  for  the  outer  wall  of  the  maxilla.  The 
first  of  these  will  be  horizontal  and  includes  the  anterior  maxillary  wall 
as  far  laterally  as  the  infraorbital  canal.  The  second  will  be  oblique 
from  above  downward  and  outward,  and  on  the  anterior  wall  of  the 
maxilla  will  extend  from  the  infraorbital  foramen  to  the  outer  ex- 
tremity of  the  malomaxillary  suture.  In  making  the  first  of  these 
transverse  cuts,  the  chisel  must  enter  the  sphenomaxillary  fossa,  which 
is  situated  above  the  maxillary  tubercle.  In  making  the  second  trans- 
verse cut,  the  chisel  must  enter  the  zygomatic  fossa.  The  distance  the 
chisel  must  traverse  from  the  infraorbital  foramen  to  the  spheno- 
maxillary fossa  is  equal  to  the  distance  between  the  anterior  border  of 
the  first  molar  tooth  and  the  hamular  process,  which  is  about  3  centi- 
meters. If,  before  beginning  the  operation,  this  distance  is  measured 
and  a  mark  is  made  on  the  outer  border  of  the  chisel,  the  cut  can  be 
made  to  the  proper  depth. 

The  hemorrhage  during  these  operations  is  very  free,  and  unless 
the  surgeon  has  made  prophylactic  constriction  of  the  carotids,  bold, 
quick,  accurate  cuts  and  quick  removal  of  the  mass  are  necessary.     The 


EXCISIONS  OF  THE  JAW-BONES.  457 

forceps  which  are  used  to  twist  out  the  bone  should  be  strong  and 
armed  with  teeth  that  will  take  a  firm  hold,  so  that  no  time  will  be  lost. 
The  cutting  of  the  bone  and  removal  of  the  mass  should  take  but  a  few 
minutes. 

As  soon  as  the  bleeding  has  somewhat  subsided,  the  temporary 
packing  is  removed,  and  in  its  place  is  substituted  a  permanent  pack 
which  is  made  with  a  gauze  strip,  1  meter  long  and  5  centimeters  wide. 
This  gauze  should  be  impregnated  with  iodoform,  xeroform,  or  col- 
loidal silver.  The  permanent  packing  begins  at  the  posterior  part,  the 
gauze  being  put  up  into  the  nasal  fossa  and  also  into  the  antrum,  if 
these  have  been  opened.  The  packing  is  done  from  behind  forward; 
and  the  end  of  the  pack  in  the  nasal  fossa  is  allowed  to  protrude  from 
the  nostril.  The  pack  must  not  be  so  tight  as  to  damage  the  mucous 
lining  of  the  cavities,  and  must  be  placed  in  an  orderly  fashion  so  that 
it  can  be  easily  withdrawn.  This  pack  having  been  placed,  the  edge  of 
the  palate  mucosa  is  sutured  directly  to  the  buccal  mucosa,  if  they  can 
be  approximated;  if  not,  the  pack  is  supported  by  a  hammock  of  sutures 
which  passes  from  the  edge  of  the  palate  mucosa  to  the  cheek.  Any 
persistent  bleeding  points  in  the  mucosa  of  the  mouth  or  the  cut  edge 
of  the  velum  can  be  controlled  with  sutures. 

The  pack  is  removed  after  twenty-four  hours  by  withdrawing  it 
from  the  nostril,  and  is  ordinarily  not  replaced.  If  the  edges  of  the 
mucous  lining  of  the  cheek  and  of  the  palate  have  not  been  directly 
coapted,  the  sutures  which  support  the  pack  are  cut.  After  this  a  nasal 
douche  and  mouth  wash  are  used  frequently.  Even  when  the  nasal 
fossa  and  antrum  are  left  wide  open,  during  the  process  of  healing  the 
size  of  the  communication  with  the  mouth  is  greatly  reduced  and  can 
later  be  closed  by  prosthesis. 

It  has  been  suggested  that  the  gap  between  the  mouth  below  and 
the  antrum  above  be  closed  with  the  nasal  septum.  This  is  to  be  done 
at  the  time  of  the  excision.  The  septum  is  cut  high  up,  in  a  line  par- 
allel with  the  palate.  This  cut  is  joined  at  its  anterior  extremity  by  a 
vertical  one  which  extends  down  to  the  floor  of  the  nose.  The  flap 
thus  freed  is  broken  at  its  base  and  swung  laterally  until  it  is  horizontal, 
when  the  outer  extremity  can  be  sutured  to  the  mucosa  of  the  cheek. 
The  velum  is  sutured  to  its  posterior  border  after  denuding.  This  is  a 
difficult  thing  to  do. 

Resection  of  the  Upper  Part  of  the  Maxilla. — The  maxilla  is  ex- 
posed by  the  same  incision  as  that  for  complete  removal.  If  a  part  of 
the  orbital  plate  is  to  be  removed,  the  contents  of  the  orbit  are  elevated 
with  a  spatula.  The  excision  is  made  with  a  chisel.  After  invading 
the  antrum,  a  wide  permanent  drainage  opening  should  be  made  through 
the  inferior  meatus  of  the  nose.     Otherwise  the  antrum  may  be  filled 


458 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


with  blood  or  pus.  After  completing  the  excision,  a  strip  of  gauze  is 
placed  in  the  antrum,  with  one  end  protruding  through  the  inferior 
meatus  and  the  nostril.  The  incision  in  the  face  is  completely  sutured. 
The  gauze  in  the  antrum  is  withdrawn  in  twenty-four  hours,  and  the 
cavity  is  irrigated  through  the  nose  with  saline,  or  alkaline  antiseptic 
solution  1  to  3. 

Total  Resection  of  the  Maxilla. — This  can  be  accomplished  by 
raising  the  tissues  of  the  face  from:  in  front  of  the  maxilla  through  an 
incision  made  in  the  upper  fornix,  in  connection  with  accessory  small 
incisions  over  the  nasal  and  malar  processes  of  the  maxilla.  This  does 
not  give  sufficient  exposure  to  deal  accurately  with  the  floor  of  the  orbit. 
A  number  of  free  cutaneous  incisions  have  been  used,  but  the  most 
efifective  and  least  objectionable  is  a  modification  of  that  proposed  by 
Weber.     (Kocher's  incision  is  shown  in  Fig.  377.)     This  latter  does 


Fig.   377. 


Pig.    379. 


Fig.    378. 


Fig.   377.      Kocher    incision   in   the   cheek   for    total   excision   of   the   maxilla. 

Fig.   378.      Showing  methods  of  dividing  the  bone  in  total  excision  of  the  maxilla. 

Fig.  379.      Incision  for  osteoplastic  resection  of  the  upper  jaw. 

not  endanger  the  nerve  supply  to  the  orbicularis  palpebrarum.  In  both 
of  these,  there  is  danger  of  a  slough  of  the  sharp  corner  of  the  flap. 
In  Kocher's  it  is  not  followed  by  serious  distortion,  but  in  Weber's 
the  lower  eyelid  may  be  pulled  down. 

In  cases  where  the  growth  is  confined  wthin  the  maxillary  bone, 
the  soft  tissues  may  be  raised  from  the  periosteum,  but  if  the  bone  is 
infiltrated,  more  tissue  must  be  removed  with  the  bone.  Wherevei  the 
soft  tissues  are  involved,  this  area  must  be  included  in  the  excision. 
The  face  flaps  are  dissected  back  until  the  pyriform  fossa  of  the  nose, 
and  the  orbit  are  opened.  The  soft  tissues  covering  the  palate  and  the 
velum  are  dealt  with  as  in  partial  resection  (see  p.  455).  If  the  orbital 
contents  are  not  to  be  removed,  they  are  elevated  from  the  floor  with  a 
spatula,  and  the  bony  walls  that  separate  the  orbit  from  the  nasal  fossa 
and  from  the  zygomatic  fossa  are  clearly  defined.     To  cut  through  the 


EXCISIONS  OF  THE  JAW-BONES.  459 

malar  process,  a  ^-circle  needle  is  inserted  through  the  anterior  end 
of  the  sphenomaxillary  fissure  so  as  to  protrude  from  the  zygomatic 
fossa  (see  Kig.  378).  This  needle  is  threaded  with  a  carrier  and  is  fol- 
lowed by  a  wire  saw,  by  which  the  malar  bone  is  sawed  through.  Next 
the  nasal  process  of  the  maxilla  is  cut  through  with  a  long-bladed  cut- 
ting forceps.  One  blade  is  placed  in  the  nose,  and  one  in  the  orbit. 
This  cut  should  also  extend  into  the  sphenomaxillary  fissure.  Lastly, 
the  alveolar  process  and  palate  are  cut  through  with  a  chisel  or  wire 
saw,  the  jaw  is  wrenched  out  with  lion  forceps,  and  the  cavity  imme- 
diately packed  with  antiseptic  gauze.  In  total  resection  of  the  maxillae 
the  operation  is  repeated  on  the  other  side. 

As  soon  as  the  bleeding  is  sufficiently  controlled,  the  cavity  and 
specimen  should  be  examined  to  see  if  the  growth  is  entirely  removed, 
and  further  excision  can  be  made. 

The  cavity  is  packed  with  a  strip  of  gauze,  one  end  protruding 
through  the  nose,  and  the  intraoral  part  of  the  wound  is  treated  (see 
p.  457).  The  face  flap  is  sutured  in  place.  If  part  has  been  excised,  it 
is  replaced  by  sliding  or  turning  flaps  from  the  forehead  or  the  lower 
part  of  the  face  and  neck.  In  case  of  a  growth  that  might  involve  the 
orbit,  before  operating,  permission  should  be  obtained  to  remove  the 
eye  if  it  is  found  advisable  to  empty  the  orbit. 

After-treatment. — After  any  of  these  operations,  the  remaining 
cavity  is  kept  clean  by  frequent  irrigations.  As  soon  as  possible,  a 
prosthetic  apparatus  should  be  made.  Where  the  orbital  plate  of  the 
maxilla  has  been  removed,  there  is  apt  to  be  a  luxation  of  the  eyeball. 
Numerous  attempts  have  been  made  to  prevent  this  by  suturing  a  piece 
of  neighboring  muscle  across  the  orbit  below  the  eye,  but  these  have 
not  been  as  satisfactory  as  a  prosthetic  apparatus  which  is  applied  early. 

OSTEOPLASTIC  RESECTIONS. 

Osteoplastic  Resections. — This  means  of  reaching  tumors  origi- 
nating from  the  base  of  the  skull  was  introduced  by  von  Langenbeck. 
He  made  the  approach  from  the  face  by  carrying  an  incision  from  the 
inner  angle  of  the  eye.  along  the  lower  border  of  the  orbit,  as  far  as  the 
middle  of  the  zygoma.  From  this  point  it  curves  downward  to  the  level 
of  the  lower  border  of  the  nostril  and  then  straight  forward  to  the  latter 
point  (Fig.  379).  The  incision  is  carried  down  to  the  bone,  but  the  flap 
is  not  elevated.  The  origin  of  the  masseter  is  cut  from  the  lower  bor- 
der of  the  malar  bone,  which  will  allow  an  elevator  to  be  inserted  into 
the  sphenomaxillary  fossa.  Von  Langenbeck  passed  a  narrow-bladed 
saw  into  the  pharynx  through  the  sphenomaxillary  fossa,  guiding  its 
inner  end  with  the  finger  of  the  left  hand  passed  into  the  pharynx  from 
the  mouth.     With  this  saw  the  jaw-bone  is  cut  above  the  alveolar  pro- 


-  460  SURGERY  OF  THE  MOUTH  AND  JAWS. 

cess  as  far  forward  as  the  pyriform  opening  of  the  nose.  A  nasal  saw 
with  a  probe  end,  run  by  a  surgical  engine  which  has  a  5  millimeter 
stroke,  would  do  this  safely  and  cleanly.  A  chisel  might  leave  a  rough 
edge,  which  would  prevent  the  subsequent  turning  out  of  the  bone  flap. 
Above,  the  nasal  process  of  the  maxilla,  the  wall  of  the  nasal  fossa,  and 
the  wall  between  the  orbit  and  temporal  fossa  are  divided  as  in  making 
a  complete  excision.  Finally,  the  zygoma  is  cut  through  by  means  of 
a  wire  saw  placed  under  the  malar  bone,  and  the  whole  mass  is  swung 
forward  with  the  base  of  the  flap  at  the  nose  as  a  hinge.  After  com- 
pleting the  removal  of  the  tumor,  the  jaw  is  returned  to  its  place,  and 
the  soft  tissues  sutured. 

Exposure  of  the  nasopharynx  through  the  mouth  is  detailed  under 
Tumors  of  the  Pharynx  (Chap.  XLT).  Gussenbauer  and  Nelaton 
have  both  described  similar  operations. 

The  deep  fossae  at  the  base  of  the  skull  can  be  approached  in  the 
midline  by  turning  the  maxillary  bones  to  each  side.  The  upper  lip  is 
incised  in  the  midline,  and  the  incision  is  carried  around  the  ala  of  the 
nose  up  to  the  inner  end  of  the  infraorbital  ridge  on  each  side.  The 
alveolar  process,  the  palate,  and  velum  are  split  in  the  midline.  Work- 
ing through  the  external  incision,  both  maxillae  are  cut  across  above  the 
alveolar  processes  with  a  chisel,  without  destroying  the  continuity  of 
the  mucous  lining  of  the  fornix  and  the  cheeks,  from  which  the  blood 
supply  is  to  be  derived.  After  severing  the  lower  attachment  of  the 
septum,  the  lower  portions  of  the  two  maxillae  can  be  turned  laterally. 
If  necessary,  the  external  nose  can  be  turned  upward,  by  cutting  the 
attachments  of  the  nasal  bones  from  the  septum  and  the  nasal  processes 
of  the  maxillae,  and  fracturing  their  attachment  to  the  frontal  bone. 

After  removing  the  tumor,  the  maxillae  are  replaced  and  wired,  and 
the  soft  parts  are  sutured.  If  packing  is  used,  it  should  be  in  the  form 
of  long  strips  which  are  let  out  through  the  nostrils.  The  operation 
just  described  is  the  operation  of  Kocher,  carried  to  the  limit  of  surgical 
possibilities.     Such  an  operation  will  very  seldom  be  indicated. 

Mortality. — The  immediate  mortality  of  total  resection  of  the 
maxilla  has  been  variously  placed  between  2.8  and  30  per  cent.  As 
pointed  out  by  C.  Schlatter,  the  difference  between  high  and  low  mor- 
tality is  not  dependent  on  the  introduction  of  asepsis,  but  on  the  adoption 
of  measures  to  prevent  aspiration  of  blood  during  the  operation. 
Heuter,  in  1867,  suggested  that  the  entire  operation  should  be  done 
without  anesthesia.  Kronlein  used  a  little  morphin  and  a  few  whiffs 
of  ether,  but  operated  mainly  under  suggestive  anesthesia.  He  has  had 
a  death  rate  of  2.8  per  cent. 

Most  operators  would  hesitate  to  undertake  so  formidable  an  oper- 
ation without  a  general  anesthesia,  but  much  can  be  done  to  lessen  the 


EXCISIONS  OF  THE  JAW-BONES.  461 

danger  of  aspiration  even  under  complete  anesthesia.  The  lateral 
position  will  help.  Tracheotomy  with  pharyngeal  packing  or  intra- 
tracheal insufflation  can  be  used  in  some  cases,  but  the  Trendelenburg 
tampon  cannula  should  be  discarded.  Preliminary  constriction  of  the 
carotids  (see  p.  631)  has  the  double  advantage  of  saving  blood  and 
limiting  the  danger  of  aspiration.  Schlatter  cites  Reyher,  v.  Lesser. 
Bryant,  Schonborn,  Kocher,  and  Fritz  Konig,  as  well  as.  himself,  as 
being  strongly  in  favor  of  this  procedure.  After  controlling  the  blood 
supply,  the  patient  can  be  placed  in  the  lateral  position,  head  somewhat 
dependent,  and  in  this  way  aspiration  is  prevented  without  the  use  of 
complicated  time-consuming  procedures. 

Prognosis. — For  carcinoma,  the  ultimate  prognosis  for  cases  re- 
quiring total  resection  has  been  very  bad,  the  majority  of  series  showing 
the  cures  amounting  to  1  per  cent  or  less.  Schlatter  states  that  in  the 
Zurich  clinic  recurrence  took  place  after  an  average  of  3.9  months  in 
all  cases  of  malignant  tumor  that  involved  the  entire  jaw.  With  early 
diagnosis  and  partial  resections  the  prognosis  is  much  better,  50  per  cent 
remaining  well  for  three  years  or  longer.  The  prognosis  for  sarcoma 
is  better  than  for  carcinoma.  It  has  not  been  considered  expedient  to 
remove  the  cervical  lymph  nodes  in  most  cases,  because  the  lymphatics 
first  involved  are  inaccessible. 

RESECTION  AND  EXCISION  OF  THE  MANDIBLE. 

Excision  of  the  condyl  was  presented  under  Ankylosis,  page  322 ; 
of  the  anterior  part  of  the  ramus,  under  Salivary  Fistula,  page  512 ; 
posterior  part  of  the  ramus,  under  Parotid  Excision,  page  520,  and  Re- 
section of  the  Body  for  Deformity,  page  301. 

Resection  of  the  Inferior  Alveolar  Process. — The  alveolar  bone 
can  be  removed  with  biting  forceps.  If,  however,  the  excision  is  to 
extend  into  the  hard  bone,  a  much  more  accurate  and  extensive  removal 
can  be  made  with  a  wire  saw.  In  front  of  the  third  molar  tooth  this  can 
be  done  from  within  the  mouth,  but  behind  the  second  molar  an  ex- 
ternal incision  is  usually  required. 

The  body  of  the  jaw  can  be  exposed  by  splitting  the  cheek  from  the 
corner  of  the  mouth  to  the  anterior  edge  of  the  masseter,  or  by  an  in- 
cision running  along  the  under  border  of  the  bone  on  one  or  both  sides. 
In  connection  with  this  inferior  incision,  the  coverings  of  the  chin  with 
the  lower  lip  may  be  split  in  the  midline,  or  at  the  corner  of  the  mouth. 

To  excise  a  portion  of  the  alveolus  and  body  but  still  preserve  the 
bony  arch  by  a  narrow  bridge  of  the  lower  border,  the  bone  is  exposed 
both  on  its  inner  and  outer  surface,  and  the  body  is  traversed  by  two 
drill  holes,  one  at  each  extremity  of  the  proposed  longitudinal  bone  cut. 
A  needle  threaded  with  a  silk  carrier  is  passed  into  one  of  these  holes 


462    .  SURGERY  OF  THE  MOUTH  AND  JAWS. 

and  out  of  the  other.  By  means  of  this  carrier  a  wire  saw  is  drawn  into 
position  for  making  the  longitudinal  cut  (Fig.  380).  Again  passing 
the  saw  through  each  of  the  drill  holes  in  turn,  the  alveolar  process  is 
cut  vertically,  liberating  the  diseased  mass.  Before  making  the  bone 
incision,  any  disease  of  the  soft  tissues  is  to  be  liberated  and  included 
with  the  bone  excision.  (Complete  resection  of  the  body  was  de- 
scribed under  Correction  of  Jaw  Deformities,  Chap.  XXI.)  Before  re- 
moving the  mental  part  of  the  body,  the  tongue  should  be  controlled  by 
transfixing  it  with  a  ligature. 

Disarticulation  of  Half  of  the  Mandible. — The  incision  is  car- 
ried along  the  lower  and  posterior  borders  of  the  jaw  nearly  to  the  lobe 
of  the  ear,  but  the  facial  nerve  and  parotid  gland  must  not  be  cut. 
The  tissues  are  dissected  from  the  outer  and  inner  surface  of  the  body, 
and  the  latter  is  cut  through  with  a  wire  saw.     The  tissues  are  freed 


Fig.  380.  Excision  of  the  lower  alveolar  process.  Tte  posterior  vertical  cut  is 
represented  as  having  been  made ;  the  anterior  is  partially  made  with  the  saw  still  In 
place.     The  saw  is  in  position  for  making  the  longitudinal  cut. 

from  the  outer  and  inner  surfaces  of  the  ramus,  and  the  body  is  drawn 
downward  and  backward ;  this  brings  the  coronoid  process  into  view. 
The  coronoid  process,  or  the  tendon  of  the  temporal  muscle  attached 
to  it,  is  cut  through.  The  condyle  is  then  twisted  out  of  the  glenoid 
cavity.  In  double  disarticulation  the  operation  is  repeated  on  the  other 
side. 

Mortality. — The  mortality  for  simple  resection  of  the  jaw  for  de- 
formity has  in  our  experience  been  nil.  For  excisions  involving  the 
full  thickness  of  the  bone,  it  is  considerably  less  than  for  total  excision 
of  the  upper  jaw,  but  when  a  piece  is  excised  in  conjunction  with  an 
excision  of  the  tongue,  the  mortality  may  be  something  between  25  and 
40  per  cent. 

Prognosis. — The  prognosis  after  excisions  for  carcinoma  of  the 
lower  jaw,  which  is  usually  of  the  hard  ulcerating  type,  is  very  much 
better  than  after  excision  for  carcinoma  of  the  body  of  the  upper  jaw. 


EXCISIONS  OF  THE  JAW-BONES.  463 

After  excising  a  carcinoma  of  the  lower  jaw,  the  lymphatics  of  the  neck 
should  be  treated  as  in  carcinoma  of  the  tongue. 

PREVENTION  OF  DEFORMITY. 

After  removal  of  one  half  of  the  upper  jaw,  if  there  are  sound  teeth 
in  the  remaining  section,  an  obturator  and  a  plate  carrying  teeth  can 
be  attached  to  the  teeth  in  the  sound  half  of  the  jaw.  If  there  are  no 
teeth  in  the  sound  jaw,  the  plate  might  be  held  in  place  by  springs  at- 
tached to  a  lower  dental  plate,  or  to  bands  placed  on  the  lower  molars. 

Not  the  least  important  point  about  an  excision  of  a  segment,  that 
includes  the  full  thickness  of  the  body  of  the  lower  jaw-bone,  is  the  im- 
mediate substitution  of  an  artificial  support  to  take  the  place  of  the 
missing  part,  or  the  adoption  of  some  means  of  preventing  the  displace- 
ment of  the  remaining  portion.  This  is  too  frequently  neglected.  By 
doing  this,  the  immediate  discomfort  is  lessened,  and  subsequent  de- 
formity is  in  a  large  measure  prevented.  After  one  half,  or  a  large 
piece,  of  the  body  is  excised,  the  remaining  fragment,  unless  supported, 
will  be  drawn  backward  and  toward  the  median  line.  The  first  effect 
of  this  is  to  relax  the  muscles  of  the  floor  of  the  mouth,  allowing  the 
tongue  and  hyoid  bone  to  fall  back.  Later,  by  scar  contraction,  the 
displacement  is  made  greater  so  that  the  lower  teeth  no  longer  articulate 
with  the  upper.  When  the  anterior  part  of  the  body  is  removed,  there 
is  no  support  to  the  muscles  taking  origin  from  the  symphysis,  and  the 
remaining  posterior  portions  of  the  body  are  both  drawn  toward  the 
midline. 

To  prevent  these  displacements,  several  means  have  been  resorted 
to.  After  removal  of  a  large  part  of  one  side  of  the  body,  or  a  dis- 
articulation of  one  half  of  the  body,  the  simplest  method  of  preventing 
displacement  is  to  wire  the  teeth  of  the  remaining  section  of  the  lower 
jaw  to  those  in  the  upper,  as  in  dressing  a  fractured  jaw.  This  method 
was  proposed  by  Dr.  Gilmer,  and  we  have  found  that  after  having  the 
jaws  wired  together  for  three  weeks  there  was  little  subsequent  dis- 
placement (Fig.  381).  It  is  especially  applicable  to  those  cases  which 
include  a  wide  excision  in  the  soft  tissues.  After  wiring  the  teeth,  the 
opening  between  the  jaws  may  be  found  to  be  limited  by  a  band  of  scar 
attached  to  the  cut  end  of  the  bone  (Fig.  382).  This  is  to  be  later  cor- 
rected by  freeing  this  band  from  its  attachment  to  the  lower  jaw  by 
surrounding  the  lower  part  of  the  band  with  a  deep  V-shaped-  incision. 
The  mouth  is  opened  to  its  fullest  extent,  and  the  defect  remaining 
after  liberating  the  scar  band  is  eliminated  by  suturing  the  edges  to  the 
mucous  membrane  of  each  side.  Sometimes  it  is  necessary  to  make  this 
V-shaper  incision  through  the  full  thickness  of  the  cheek  (Fig.  383). 

The  other  plans  of  preventing  displacement  consist  in  substituting 


464 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


bone  or  some  forei.gn  substance  for  the  section  of  bone  removed.  The 
simplest  way  of  doing  this  is  to  reproduce  the  removed  portion  from 
dental  modeling-  compound,  setting  the  artificial  section  down  in  the 
trough  from  which  the  bone  was  removed.  The  modeling  compound, 
having  been  softened  in  hot  water,  can  be  moulded  to  the  exact  size  and 
shape  desired,  right  at  the  operation.  This  may  be  steadied  in  place 
by  a  few  sutures  passing  through  its  substance,  attaching  it  to  the  bone 


Fig.    38 


Fig.    3S4. 


Fig.  381.  Showing  occlusion  of  the  teeth,  after  excision  of  one-half  of  the  mandi- 
ble, when  the  remaining  half  of  the  lower  jaw  was  immediately  wired  to  the  upper. 
This  photograph  was  taken  some  weeks  after  the  wires  were  removed. 

Fig.  382.  Showing  band  of  sear  tissue  that  binds  the  jaws  together,  after  re- 
moval of  one  half  of  the  jaw  with  part  of  the  adjacent  tissue. 

Fig.  383.  Showing  opening  obtained  in  the  preceding  case,  after  freeing  the  lower 
attachment  of  the  scar  band,  as  described  in  the  text. 

Fig.  384.  Marten  splint  for  replacing  an  excised  portion  of  the  lower  jaw.  (For 
more  modern  adaptation  of  this  idea,  see  Fig.  G7,  Cryer's  adaptation.) 

or  the  soft  tissues.  The  jaw  can  be  made  more  secure  by  wiring  the 
upper  to  the  lower  teeth.  As  soon  as  possible,  a  prosthetic  apparatus 
which  carries  teeth  replaces  this  temporary  splint.  It  is  made  to  fit 
the  remaining  part  of  the  jaw  and  teeth,  and  fits  snugly  into  the  space 
which  was  occupied  by  the  temporary  splint.  A  more  elaborate  method 
of  doing  this  same  thing  is  the  use  of  the  Marten  split  (Fig.  384).  In 
a  case  of  Schlatter's,  in  which  he  removed  several  centimeters  of  the 
lower  jaw  in  a  girl  ten  years  old,  before  the  girl  was  eighteen  years  old 


EXCISIONS  OF  THE  JAW-BONES. 


465 


the  artificial  jaw  had  to  be  replaced  four  times  on  account  of  the  grov/th 
of  the  bone. 

The  foregoing  methods  have  the  advantage  to  the  general  surgeon 
that  he  can  prepare  them  himself  at  the  operation,  or  have  them  con- 
structed beforehand  and  adapt  them  to  the  conditions  resulting  from 
the  operation. 

C.  Marten,  of  Lyons,  was  possibly  the  first  to  attempt  the  prevention 
of  deformity  by  immediate  prosthesis.  His  splint,  which  is,  in  general 
size  and  form,  a  reproduction  of  the  segment  of  bone  to  be  excised,  is 
constructed  of  gutta-percha.  It  is  hollow  and  is  perforated  with  small 
holes  on  its  under,  inner,  and  outer  surfaces,  and  over  one  of  these  a 
short  piece  of  rubber  tubing  is  attached.  The  gutta-percha  splint  is 
made  longer  than  is  needed  and  is  cut  the  proper  length  at  operation. 
By  means  of  wires,  or  screws  and  small  silver  plates,  the  splint  is  at- 


Fig.    385.      Showing   silver   wire   bridge    in    place,    replacing   one   half    of    the    body    of 
the  lower  jaw. 

tached  to  the  ends  of  the  bone,  and  is  allowed  to  stay  in  place  until  it 
can  be  replaced  with  a  permanent  prosthetic  apparatus.  During  the 
course  of  convalescence,  the  wound  is  irrigated  at  frequent  intervals 
with  water,  or  some  solution  forced  into  the  splint  through  the  rubber 
tube.  According  to  reports,  this  splint  gives  excellent  results,  but 
probably  no  better  on  the  whole  than  can  be  obtained  with  a  properly 
fitted  splint  of  modeling  compound.  When  it  is  intended  to  use  either 
of  these  splints,  it  is  preferable  to  avoid  a  long  incision  at  the  lower 
border  of  the  jaw.  Failure  of  primary  union  would  leave  the  splint 
without  external  tissue  covering.  A  small  drainage  opening  should  be 
made  at  the  bottom  of  the  sulcus.  Both  can  be  used  after  a  disarticu- 
lation. Another  plan  is  to  make  a  bridge  of  strong  wire.  No.  10,  and 
insert  its  ends  into  holes  in  the  cut  surface  of  the  bone.  In  order  to 
prevent  the  wires  from  gradually  pressing  deeper  into  the  bone  and  thus 
lessening  the  gap,  each  wire  is  crooked  into  a  shoulder,  near  its  free 


466  SURGERY  OF  THE  MOUTH  AND  JAWS. 

end,  which  rests  against  the  end  of  the  bone  at  each  of  the  drih  holes. 
Such  a  bridge  can  be  prepared  beforehand,  much  longer  than  will  be 
needed ;  at  the  operation  the  surgeon  can  cut  it  to  the  proper  length  and 
bend  in  the  shoulders  at  the  proper  places  (Fig.  385). 

Partsch  completed  the  arch  by  attaching  a  simple  band  of  metal  to 
the  outer  surface  of  the  remaining  ends  of  the  bone,  with  wire.  It  is 
intended  that  both  the  wire  splint  and  Partsch's  band  be  allowed  to  heal 
in  place.  For  this  reason  they  should  be  made  of  some  bland  metal,  such 
as  silver.  If  a  sinus  persists  that  wiU  not  heal  on  the  injection  of  bis- 
muth paste,  or  if  part  of  the  splint  remains  exposed  and  it  cannot  be 
buried  by  a  fiap  operation,  then  all  or  part  of  the  splint  will  have  to  be 
removed.  If  the  splint  can  be  made  to  stay  in  place  several  months, 
much  good  is  accomplished.  Gilmer  is  our  authority  for  stating  that 
bridges  or  splints,  which  are  attached  to  the  teeth  only,  are  never  satis- 
factory as  a  permanent  means  of  holding  the  fragments  in  place  after 
removal  of  a  complete  section  of  the  lower  jaw. 

A  number  of  more  elaborate  splints  have  been  devised  to  prevent 
displacement  of  the  remaining  portion  of  the  mandible.  One  of  the 
earlier  was  a  pair  of  interlocking  flanges,  which  were  constructed  so 
that  one  half  was  attached  to  the  teeth  of  the  upper  and  one  half  to 
those  of  the  lower  jaw.  These  are  so  arranged  that  the  jaws  can 
separate,  but  the  half  mandible  cannot  be  drawn  toward  the  midline. 
These  are  seldom  used  except  as  corrective  measures.  Where  no  pre- 
ventive measures  have  been  used,  and  displacement  of  the  jaw  frag- 
ments has  occurred,  much  has  been  accomplished  by  the  use  of  the 
inclined  planes.  A  lug  or  a  metal  plane  is  attached  to  a  lower  tooth, 
set  obliquely,  and  resting  against  the  outer  surface  of  a  corresponding 
upper  tooth  or  a  plane  attached  to  the  upper  tooth.  These  inclined 
planes  are  so  arranged  that,  as  the  jaws  close,  the  lower  jaw  fragment 
is  forced  to  travel  outward  as  it  moves  upward.  In  this  way  some  very 
good  results  have  been  accomplished  in  bad  cases.     (See  Fig.  6G). 

Small  defects  have  been  filled  by  turning  a  bone  flap  from  the  lower 
border  of  the  neighboring  intact  part  of  the  jaw.  Ivory  splints 
have  been  successfully  employed.  According  to  Magnuson,  ivory 
heals  very  rapidly  in  situ,  and  is  replaced  by  bone.  With  a  care- 
ful secondary  operation,  a  piece  of  rib  can  be  inserted  between  the 
cut  ends  of  the  bone,  through  an  external  incision.  Such  transplanted 
bone  must  retain  its  periosteum,  otherwise  it  may  eventually  be  ab- 
sorbed. The  space  in  which  it  is  imbedded  must  not  communicate  with 
the  mouth,  as  the  wound  should  remain  aseptic.  Therefore,  it  seems 
to  us  that  bone  transplantation  cannot  be  done  at  the  primary  operation 
with  any  reasonable  hope  of  success.  Dr.  Judd,  of  Rochester,  tells  us 
that  he  has  succeeded  in  retaining  a  section  of  rib  in  a  cavity  that  had 


EXCISIONS  OF  THE  JAW-BONES.  467 

communicated  with  the  mouth,  but  he  considers  it  necessary  to  retain 
the  periosteum -both  of  the  rib  and  the  jaw.  We  saw  him  do  one  such 
an  operation  for  a  cystic  adamantinoma,  but  there  are  few  conditions  hi 
which  it  is  advisable  to  remove  all  of  the  bone  and  leave  the  peri- 
osteum. We  have  had  a  number  of  successful  cases  where  we  have 
transplanted  rib  or  cartilage  into  the  tissues  in  clean  cavities,  and  re- 
tained the  periosteum  only  on  the  transplanted  bone. 

A  resected  portion  of  rib  has  been  temporarily  enveloped  in  a  skin 
flap,  and  after  acquiring  a  source  of  nutrition,  has,  with  its  skin  en- 
velope, been  transplanted  into  the  jaw.  In  one  instance,  in  a  rapidly 
growing  carcinoma  which  involved  half  the  jaw,  the  submaxillary 
region,  and  the  lower  part  of  the  face,  the  patient  elected  to  take  his 
chances  on  an  operation.  The  nature  of  the  growth  demanded  that 
this  be  done  at  a  single  sitting.  Before  invading  the  mouth  tumor,  we 
freed  the  flap  of  tissue  which  extended  from  the  level  of  the  mastoid 
process  to  10  centimeters  below  the  clavicle,  having  its  attachment 
above.  This  flap  included  the  sternomastoid  muscle  and  the  middle 
8  centimeters  of  the  clavicle.  After  removing  the  gland-bearing  tissue 
of  the  neck,  the  borders  of  the  remaining  defect  were  drawn  together. 
Then  the  tumor,  including  three  fourths  of  the  body  of  the  jaw,  the 
lower  half  of  the  cheek,  the  lower  lip,  and  the  tissues  of  the  submaxillary 
region,  was  removed  in  one  block. 

The  infraclavicular  portion  of  the  flap  was  turned  upward  and 
around  the  section  of  clavicle.  The  flap  was  brought  forward  to  re- 
place the  defect  in  the  face.  The  clavicular  section  being  fastened  to  the 
cut  ends  of  the  jaw-bone,  and  the  infraclavicular  portion  of  the  flap  be- 
ing used  to  replace  the  deficient  buccal  mucosa,  left  a  submaxillary 
defect  which  was  packed  with  gauze.  Mechanically  this  worked  out 
fairly  well,  and  had  the  patient  survived,  we  believe  the  vitality  of  the 
bone  flap  would  have  been  insured,  from  the  fact  that  it  was  surrounded 
by  well-nourished  tissues  which  are  normally  attached  to  it.  Un- 
fortunately, the  patient  did  not  long  survive  the  operation. 

Some  patients  with  carcinoma  are  willing  to  take  desperate  chances. 
But  it  is  questionable  whether  such  an  operation  should  ever  be  per- 
formed at  a  single  sitting. 

After  the  removal  of  one  ramus  no  deformity  occurs,  but  if  for  any 
reason  both  rami  are  removed,  the  body  of  the  jaw  should  be  wired  to 
the  upper  until  one  or  both  rami  are  replaced  by  bone  grafts  at  an 
immediate  or  a  secondary  operation. 


CHAPTER  XXXIl. 

DISEASES  AND  TUMORS  OF  THE  UP. 

Congenital  clefts  of  the  lips  and  palate  were  described  in  Chap. 
XIV. 

INJURIES. 

Bruises  of  the  lip  may  cause  great  swelling,  but  as  a  rule  need  no 
special  treatment.  If  seen  early,  ice  may  be  applied.  The  lips  may  be 
deeply  cut,  usually  from  blows  which  drive  the  lip  against  the  teeth. 
The  cut  may  be  entirely  through  the  lip,  or  it  may  be  only  on  its  inner 
surface.  In  either  case,  the  coronary  artery  may  be  cut.  Wide  cuts, 
or  cuts  that  extend  entirely  through  the  lip,  should  be  immediately  and 
accurately  sutured,  but  the  sutures  should  not  be  drawn  very  tight,  as 
swelling  will  occur.  Usually  the  sutures  will  control  the  bleeding.  If 
there  is  much  sloughing  tissue,  this  may  be  trimmed  with  scissors.  A 
slight  purulent  discharge  from  the  surface  of  the  wound  does  not  pre- 
clude immediate  suture,  but  if  there  is  much  inflammation  of  the  sur- 
rounding tissue,  suture  is  to  be  postponed  until  this  subsides. 

SCARS. 

The  lips  may  show  scars  from  various  causes,  the  most  interesting 
of  which  are  fine  radiating  scars  observed  most  commonly  about  the 
angles  of  the  mouth,  and  which  extend  to  the  buccal  surface.  These 
are  due  to  a  former  syphilitic  infiltration  and  are  to  be  differentiated 
from  perleche. 

Deforming  scars  are  to  be  excised  and  repaired  according  to  the 
principles  already  given    (Fig.  38G). 

LIP  CRACKS  OR  CHAPS. 

These  are  common  and  often  annoying.  They  occur  most  com- 
monly either  at  the  corners  of  the  mouth,  or  in  the  middle  of  the  mucous 
surface.  Persistent  cracks  or  ulceration  in  the  corners  of  children's 
mouths,  becoming  infected,  may  lead  to  lymphatic  hypertrophy  of  the 
lip.  Chronic  cracks  or  ulcers  at  the  corners  of  the  mouth  in  children 
are  sometimes  due  to  syphilis.  Simple  cracks  or  chaps  occur  usually  in 
winter,  and  in  some  persons  they  are  recurrent  and  annoying;  especially 
a  crack  that  comes  in  the  middle  of  the  lower  lip,  being  slightly  indu- 
rated, with  every  movement  of  the  lip  tends  to  become  deeper.     It 

4G8 


DISEASES  AND  TUMORS  OF  THE  LIP, 


469 


bleeds  occasionally  and  persists  throughout  the  winter.  It  seems  to  be 
dependent  upon  the  anatomical  configuration  of  the  lip,  and  persists  on 
account  of  the  induration  of  its  edges  and  the  mobility  of  the  lip.  If 
the  two  borders  can  be  strapped  together  with  an  adhesive  plaster  for 
a  week  or  so,  it  will  heal ;  but  this  is  difficult  to  do,  and  the  remaining 
depression  is  very  liable  to  open  again.  In  the  marked  cases  it  is  ad- 
visable to  excise  the  fissure  with  a  knife  and  approximate  the  borders 
with  deep  sutures.  This  may  be  followed  by  permanent  relief.  Lesser 
fissures  are  to  be  treated  by  the  application  of  some  rather  stiff  lip 
salve,  to  which  an  antiseptic  may  be  added  in  appropriate  cases. 

SIMPLE  HYPERTROPHY. 

Either  lip  may  be  enlarged  from  the  habit  of  lip-sucking.  Perma- 
nent simple  enlargement  of  either  lip  often  persists  to  an  annoying 
extent  after  malocclusions  have  been  corrected. 


Fig.   386.      Deformity  of  the  lower  lip,  due  to  sear  resulting  from  noma. 


MACROCHEILIA. 

This  may  be  due  to  a  chronic  lymphangitis,  and  is  usually  dependent 
upon  a  chronic  inflammation  of  fissures,  eczema,  etc.  It  usually  occurs 
in  sickly  children.  When  such  a  condition  is  noticed,  great  care  should 
be  taken  to  cure  or  prevent  fissure,  eczema,  etc.,  of  the  lips.  Chronic 
enlargement  of  the  lip  in  an  adult  may  be  due  to  syphilis,  and  in  infants., 
syphilis  may  cause  a  diffuse  infiltration  of  the  borders.  If  sufficiently 
pronounced  to  demand  correction,  it  can  be  done  by  excising  a  wedge- 
shaped  portion  which  will  resemble  a  section  from  an  orange.  The 
long  axis  of  the  base  of  this  wedge  is  parallel  with  the  mouth  slit.  The 
base  of  the  wedge  is  to  be  at  the  junction  of  the  edge  of  the  lip  with  its 
oral  surface,  and  the  edge  of  the  wedge  is  to  be  taken  from  deep  in 
the  lip,  with  a  razor-edged  knife.  Before  doing  this,  both  ends  of  the 
lower  coronary  artery  should  be,  at  least  temporarily,  controlled.     A  less 


470  SURGERY  OF  THE  MOUTH  AND  JAWS. 

accurate  correction  can  be  made  by  simply  removing  a  wedge  from  the 
central  part  of  the  lip,  that  includes  an  equal  amount  of  the  mucous  and 
cutaneous  surfaces. 

FURUNCLE. 

Furuncle  or  carbuncle  of  the  lips  and  face  is  of  special  interest  be- 
cause of  the  relative  frequency  with  which  it  has  been  followed  by 
thrombosis  of  the  cavernous  sinus  of  the  dura  mater.  The  explanation 
given  for  this  is  that  the  facial  vein  communicates  freely  with  the  oph- 
thalmic and  that  neither  contains  valves. 

PHLEGMON. 

Phlegmon  may  develop  in  the  lips,  and  this  is  sometimes  seen  after 
the  bites  or  stings  of  insects.  There  is  always  considerable  edema. 
Ice  is  to  be  applied  in  the  early  stage,  and  an  incision  is  to  be  made  as 
soon  as  pus  is  located. 

GANGRENE. 

Gangrene  of  the  lips  is  almost  always  due  to  cancrum  oris  (see  p. 

355). 

HERPES. 

Herpes  of  the  lips  is  common.  (See  Herpes  of  the  Mouth,  p.  350.) 
On  the  lips  the  vesicles  rupture  and  dry,  leaving  a  yellow-brown  crust. 

PERLECHE. 

Perleche  is  a  superficial  ulceration,  limited  to  the  angles  of  the 
mouth,  which  appears  in  children  of  school  age,  and  is  of  interest  chiefly 
because  it  has  to  be  distinguished  from  syphilis.  There  is  roughness 
of  the  skin  at  the  angles,  which  is  marked  by  numerous  radiating 
grooves.  The  skin  of  the  area  is  somewhat  brownish  in  color,  and 
sometimes  moist  fissures  appear  at  the  corners.  There  is  a  burning 
sensation  which  leads  the  children  to  lick  the  patches,  whence  the  name. 
By  most  observers  it  is  believed  to  be  due  to  an  infection.  Lemaistre 
believes  it  to  be  due  to  an  aerobic  streptococcus.  The  treatment  consists 
in  the  application  of  tincture  of  iodin,  or  a  drying  powder.  It  is  to  be 
distinguished  from  syphilis  by  its  localization,  the  fact  that  the  radiating 
grooves  do  not  extend  to  the  mucous  surface  of  the  cheek,  and  that  in 
healing  it  leaves  no  scar, 

TUBERCULOSIS  OF  THE  LIPS. 

Lupus  may  occur  on  the  lip  in  conjunction  with  hipus  of  other  parts 
of  the  face.  Ordinary  tuberculous  ulcer  occurs  but  rarely  on  the  lip. 
(See  Tuberculosis  of  Tongue,  p.  533,  which  it  resembles.) 


DISEASES  AND  TUMORS  OF  THE  LIP.  471 

SYPHILIS. 

The  lip  is  a  common  site  for  extragenital  chancre,  which  does  not,  as 
does  the  genital  chancre,  show  a  characteristic  size  and  appearance,  but 
does  always  at  some  stage  show  an  indurated  base.  It  may  vary  in 
size  from  a  dime  to  a  dollar  and  is  usually  ulcerated.  The  ulceration 
may  be  evident  or  hidden  by  thick  crusted  scabs.  It  is  differentiated 
from  carcinoma  by  its  acute  onset,  its  spontaneous  recovery  at  the  end 
of  five  or  six  weeks,  the  early  and  marked  enlargement  of  the  lymph 
nodes,  its  disappearance  under  antisyphilitic  treatment,  and  the  presence 
of  Spirocheta  pallida.  Mucous  patches  are  very  common  on  the  inner 
surface  of  the  lip  in  the  secondary  stage  of  syphilis ;  deep  in  the  fornix, 
where  subject  to  little  irritation,  they  are  somewhat  of  the  character  of 
the  patches  under  the  tongue,  but  not  so  elevated.  At  the  corners  of 
the  mouth,  where  they  are  very  common,  they  are  apt  to  ulcerate.  At 
the  edge  of  the  lip  a  mucous  patch  may  sometimes  be  seen  to  be  con- 
tinuous with  a  cutaneous  papule.  It  is  always  to  be  remembered  that 
the  moist  lesions  of  the  first  and  second  stage  of  syphilis  are  fruitful 
sources  of  contagion. 

A  diffuse  infiltration  of  the  borders  of  the  lips  may  occur  in  syphi- 
litic infants,  which  is  marked  by  stiffness,  a  red-brownish  color  and  a 
peculiar  glossiness,  and  the  development  of  radial  fissures. 

Gumma  may  develop  in  the  lip  and  cause  great  destruction.  (See 
Syphilis  of  the  Mouth  and  Syphilis  of  the  Tongue.) 

CYSTS. 

Cysts  of  the  muciparous  glands  of  the  lip  are  not  uncommon. 
Usually  there  are  one  or  several  isolated  cysts  projecting  on  the  mucous 
surface,  but  there  may  be  so  many  as  to  cause  an  eversion  of  the  lip. 
They  are  small,  round  bodies,  usually  freely  movable,  and  may  appear 
bluish. 

Single  cysts  are  to  be  grasped,  with  their  mucous  covering,  with 
fine-toothed  forceps,  and  the  projecting  portion  cut  away  with  scissors, 
the  remaining  portion  being  grasped  and  shelled  out.  For  a  general 
cystic  condition  of  these  glands,  a  mucous  flap  is  to  be  turned  down, 
and  the  mass  dissected  out;  after  which  the  remnant  of  mucous  mem- 
brane is  to  be  sutured  back  into  place.  If  the  mucous  covering  is  too 
thin  or  ragged  to  give  promise  of  living,  flaps  can  be  turned  from  the 
lining  of  both  cheeks  and  sutured  in  place. 

HEMANGIOMA. 

Angioma  of  the  Up  is  not  uncommon.  In  its  early  state,  it  usually 
shows  a  small  purple  spot,  perhaps  slightly  elevated,  which  is  com- 
pressible, but  which  returns  to  its  original  size  when  the  pressure  is 


472  SURGERY  OF  THE  MOUTH  AND  JAWS. 

released.  From  this  it  may  extend  until  most  of  one  or  both  lips  and 
a  large  part  of  the  face  are  converted  into  a  purplish  tumorous  mass. 
When  seen,  they  are  unmistakable.  There  is  a  form  of  superficial  an- 
gioma known  as  "wine  spots,"  which  may  appear  on  any  part  of  the 
body.  They  form  a  sharply  limited  reddish-purple  stain.  In  infants 
an  angioma  may  be  pedunculated. 

As  soon  as  an  angioma  shows  a  disposition  to  spread,  it  should  be 
destroyed ;  in  this  way  the  patient  may  be  saved  from  one  of  the  more 
extensive  type.  For  the  extensive  angiomata,  Wyeth's  method  of 
obliteration  with  boiling  water  is  often  the  best  treatment.  In  some  part 
of  the  tumor  20  cubic  centimeters  or  less  of  boiling  water  is  injected 
with  a  hypodermic  syringe.  The  injection  of  one  part  is  to  cease  as  soon 
as  the  skin  turns  white,  but  sloughing  does  not  seem  to  follow.  Some 
weeks  later  another  part  is  injected,  and  so  on  until  the  tumor  is  oblit- 
erated. The  surgeon  wears  heavy  rubber  gloves  to  protect  his  hands, 
and  the  syringe  should  rest  in  a  basin  of  boiling  water  until  immediately 
before  it  is  to  be  used.  The  water  in  the  syringe  should  be  of  boiling 
temperature.  For  injections  of  any  extent  a  general  anesthetic  is 
needed,  but  as  the  injection  takes  but  a  few  minutes,  gas  with  oxygen 
is  appropriate.  The  electric  needle  and  also  the  Paquelin  cautery,  thrust 
deep  into  the  tumor,  are  used  for  destroying  cavernous  angiomata,  but 
whenever  possible,  it  is  better  to  dissect  out  the  mass  with  a  sharp 
knife.  For  destroying  large  "wine  spots,"  the  repeated  action  of  radium 
is  most  effective. 

ENDOTHELIOMA. 

We  have  seen  two  cases  of  diffuse  endothelioma  of  the  face,  which 
caused  considerable  deformity,  and  several  smaller  ones  (Fig.  387). 
None  of  these  presented  any  of  the  characteristics  of  mixed  salivary 
gland  tumors.  The  tumor  was  soft,  feeling  almost  like  an  angioma. 
The  overlying  skin  was  coarse  and  deeply  pitted  at  the  pores.  A 
microscopical  section  showed  masses  of  endothelial  cells  and  fibrous 
tissue  which  had  replaced  most  of  the  normal  tissue. 

The  treatment  of  the  larger  tumors  was  not  very  satisfactory,  but  by 
turning  back  as  thin  a  skin  flap  as  seemed  compatible  with  nutrition  and 
then  dissecting  out  masses  of  the  tumor,  considerable  improvement  was 
obtained  (Fig.  388).  There  was  always  profuse  hemorrhage,  and  in 
more  severe  cases,  we  had  to  do  several  operations  before  the  best 
result  was  obtained,  because  of  the  fear  that  sloughing  of  the  skin  might 
follow  a  too  radical  operation.  The  coarseness  of  the  skin  persisted, 
and  it  was  not  possible  to  perfectly  restore  the  contour  of  the  lip  and 
the  ala  of  the  nose.  Injections  of  boiling  water  proved  ineffectual  in 
the  one  case  in  which  they  were  tried. 


DISEASES  AND  TUMORS  OF  THE  LIP. 


473 


WARTS  AND  PAPILLOMATA. 

On  the  lips  these  are  not  uncommon.  In  two  specimens  in  the 
Hunterian  Museum,  in  London,  papillomata  of  the  lip  had  developed 
true  horn.  Papillomata  should  be  removed,  both  because  they  are  un- 
sHghtly,  and  because  they  may  be  an  early  stage  of  cancer.  The  same  is 
true  of  a  chronic  scurfy  patch,  which  may  appear  at  the  border  of  the 
lip  in  persons  who  have  reached  the  cancer  age.  These  may  persist 
for  years,  and  yet  a  microscopical  examination  may  show  them  to  be 


Pig.   387. 


Fig.    388. 


Fig.   387.      Lympliangioma  of  the  face  in  a  young  girl. 

Fig.   388.      Case  sliown  in  preceding  figure,  after  operation.     A  part  of  tlie  face  tis- 
sue was  removed  up  as  far  as  tlae  orbit,  including  a  section  from  the  ala. 


squamous  cell  cancer  or  rodent  ulcer.  In  some  instances  they  gave  a 
history  of  having  apparently  disappeared  at  times  and  returning,  so  this 
should  not  mislead  one  into  considering  them  simple.  They  may  be  de- 
stroyed with  lunar  caustic  or  chromic  acid,  but  a  safer  plan  is  to  make  a 
fairly  wide  V-shaped  excision  of  the  full  thickness  of  the  lip.  One  can 
afford  to  take  no  chances  when  dealing  with  carcinoma,  as  these  indolent 
patches  and  warts  often  take  on  rapid  growth  after  being  irritated  by 
a  partial  excision  or  cauterization. 


CHAPTER  XXXIII. 

CANCER  OF  THE  LIP. 

Cancer  is  more  common  on  the  lower  than  the  upper  lip,  and  much 
less  common  in  women  than  in  men.  According  to  Heimann,  out  of 
509  cases  of  carcinoma  of  the  lower  lip,  473  cases  were  in  males  and 
36  in  females.  Smoking  has  been  advanced  as  a  cause  of  carcinoma. 
It  often  occurs  at  the  side  at  which  a  pipe  is  habitually  held,  but 
may  arise  at  another  site  and  in  persons  who  do  not  smoke.  It  is 
more  common  among  the  inhabitants  of  the  country,  which  may  be  due 
to  the  greater  exposure  and  consequent  changes  in  the  skin.  Any 
chronic  change  of  the  skin  may  be  the  starting  point  of  carcinoma,  as 
may  any  chronic  irritation.  Leucoplakia  (see  Chap.  XXXVI)  may 
appear  in  one  or  several  patches  on  the  lip,  and  these  may  be  followed 
by  carcinoma.  It  is  more  frequent  as  age  advances,  but  when  it  does 
occur  in  younger  adults,  is  very  malignant. 

Carcinoma  of  the  upper  lip  is  usually  of  the  type  known  as  rodent 
ulcer,  a  carcinoma  of  the  sebaceous  glands,  which  is  not  very  malignant 
either  locally  or  in  affecting  the  lymph  nodes.  Carcinoma  of  the  lower 
lip  is  usually  of  the  squamous  type  and  occurs  clinically  in  two  forms : 
(1)  The  flat  ulcer,  which  appears  at  the  mucocutaneous  border,  ad- 
vances slowly,  remains  shallow,  is  surrounded  by  little  induration,  and 
in  the  past  has  not  been  supposed  to  commonly  invade  the  lymphatics 
early.  This  form  of  carcinoma  may  persist  for  years  and  may  even 
scar  over  only  to  reappear.  (2)  The  other  variety  shows  more  eleva- 
tion of  the  borders,  much  more  induration,  and  deeper  ulceration.  It 
has  a  distinct  tendency  to  run  along  the  mucous  surface  into  the  cheek 
or  gum.    It  early  invades  the  lymph  nodes  and  is  very  malignant. 

DIAGNOSIS. 

The  diagnosis  of  a  well-developed  carcinoma  of  the  lip  is  usually 
simple  and  rests  upon  the  ulceration,  or  scaly  patch,  surrounded  by 
induration,  and  its  chronicity — it  having  as  a  rule  persisted  for  several 
months  or  years.  Later  in  the  disease  there  is  salivation,  cachexia, 
fetor,  and  enlargement  or  ulceration  of  the  lymph  nodes  of  the  neck. 
The  patient  eventually  dies  of  exhaustion  or  pneumonia,  but  very  rarely 
from  general  metastasis.  It  is  difficult  to  differentiate  between  a  simple 
papilloma  and  a  carcinoma,  but  a  papilloma  of  the  mucous  border 
should  be  regarded  as  a  carcinoma  until  proved  otherwise  by  a  very 

competent  microscopist. 

474 


CANCER  OF  THE  LIP.  475 

Occasionally  chancre  has  been  mistaken  for  carcinoma.  The  history 
of  the  case,  the  length  of  time  that  the  sore  has  persisted,  and  the  early 
involvement  of  the  lymph  nodes  should  give  a  hint  that  would  at  least 
call  for  a  microscopical  examination.  A  Wassermann  test  does  not  ex- 
clude carcinoma.  Before  carcinomatous  glands  become  palpable,  carci- 
noma of  the  lip  usually  presents  an  unmistakable  picture.  It  is  stated 
that  the  glands  are  not  involved  in  75  per  cent  of  cases,  v^rhich  is  proba- 
bly a  great  exaggeration.  It  is  often  very  difficult  to  feel  small  lymph 
nodes  even  in  thin  persons.  So  often  have  we  found  enlarged  nodes  at 
operation,  when  none  could  be  felt  previously,  that  we  place  no  value 
on  a  negative  result  from  such  an  examination.  The  rather  general 
belief  in  the  profession  that  the  flat  ulcers  invade  the  lymph  nodes  late, 
or  not  at  all,  is  now  hardly  acceptable.  While  there  is  apparently 
clinical  evidence  to  support  this  view,  still  more  recent  careful  observa- 
tions tend  to  refute  it.  The  length  of  time  the  carcinoma  can  lie  dor- 
mant in  the  cervical  lymphatics  probably  has  much  to  do  with  it.  We 
recently  saw  a  case  of  rapidly  growing  squamous  carcinoma  of  the 
submaxillary  nodes  in  a  man  who  had  a  healed  scar  on  the  lip,  where  a 
flat  ulcer  which  existed  two  years  had  been  destroyed  with  caustic 
eight  years  previously.  Examples  of  lymphatic  infection  appearing  two 
or  three  years  after  the  destruction  of  the  lip  ulcer  are  not  at  all  un- 
common. On  the  other  hand,  nodes  may  be  enlarged  from  absorption 
of  septic  material  from  the  ulcer  or  from  accidental  causes. 

While  it  is  important  to  make  a  diagnosis  in  advanced  cases,  it  is 
even  more  important  to  make  a  diagnosis  of  the  incipient  ones.  Every 
chronic  papule,  wart,  tumor,  or  abrasion  of  the  lips  in  persons  who  have 
reached  the  cancer  age  should  be  excised  and  subjected  to  a  micro- 
scopical examination.  If  there  is  any  doubt  in  younger  persons,  they 
should  be  given  the  benefit  of  the  same  procedure;  for,  though  less 
frequently,  cancer  does  occur  under  thirty  years,  and  it  is  then  always 
very  malignant. 

TREATMENT. 

As  already  stated,  incipient  and  early  carcinoma  of  the  lip  can  be 
destroyed  with  caustics,  x-ray,  or  radium.  But  to  be  safe,  the  destruc- 
tion must  be  deep,  and  when  caustic  is  used,  the  resulting  defect  requires 
more  time  to  heal  and  leaves  more  scar  than  does  a  clean  excision.  In 
certain  instances  the  prejudice  of  the  patient  against  "the  knife"  might 
force  one  to  adopt  such  measures.  It  is  probable  that  both  radium  and 
the  x-ray  are  more  efficient  than  caustics.  Although  they  will,  when 
properly  applied,  destroy  the  local  growth,  they  can  have  little  or  no 
efifect  on  infected  lymph  nodes.  Although  it  may  be  possible  that  slow- 
growing  carcinomata  of  the  lip  infect  the  lymphatics  less  early  than  at 
most  other  sites,  still  it  is  a  safe  rule  to  regard  them  as  infected  in 


476  SURGERY  OF  THE  MOUTH  AND  JAWS. 

every  case  of  carcinomatous  ulceration  or  induration,  and  to  remove 
them  accordingly.  We  have  no  right  to  assume  that  because  the  lymph 
nodes  are  not  pulpable  they  are  not  infected;  and  the  only  safe  plan  is  to 
remove  them  in  every  instance  zvhere  there  is  a  definite  carcinomatous 
ulceration  and  induration,  no  matter  how  small.  The  nodes  first  in- 
fected are  the  submaxillary  and  the  submental,  and  later  the  deep 
cervical.  The  extent  to  which  the  lymphatics  are  to  be  removed  is  to 
be  determined  by  the  clinical  character  of  the  growth  and  the  special 
indications  as  found  at  operation.  If  no,  or  only  slight,  enlargement 
of  the  submental  or  submaxillary  lymph  nodes  is  found  after  turning" 
down  the  skin  flap,  then  one  may  content  himself  with  removal  of  the 
tissue  that  carries  these,  and  the  superior  deep  and  the  superficial  cervi- 
cal nodes  en  masse.  If,  however,  the  superior  cervical  are  palpably  en- 
larged, then  all  the  cervical  nodes  should  be  included  on  one  or  both 
sides.  This  is  a  more  conservative  course  than  is  advocated  in  print 
by  some  surgeons,  but  it  is  our  present  rule.  While  it  is  not  proper  to 
neglect  the  lymphatics  because,  possibly,  the  majority  of  these  tumors 
infect  them  only  late  in  the  disease ;  on  the  other  hand,  patients  should 
not  be  subjected  to  needless  surgery.  There  is  some  presumption  in 
the  attitude  that  the  only  risk  the  patient  runs  is  in  not  making  the 
operation  sufficiently  extensive.  There  is  the  possibility  that  there  will 
be  some  infection  of  the  wound,  and  a  prolonged  operation  complicated 
by  an  infected  deep  dissection  of  the  neck,  especially  in  old  persons, 
may  be  a  serious  matter.  This  is  not  our  attitude  toward  the  lymph 
nodes  in  the  presence  of  a  cancer  of  the  tongue.  Then  an  attempt  is 
made  in  every  instance  to  remove  all  of  the  lymph  nodes  on  at  least 
one  side  of  the  neck,  but  there  is  abundant  clinical  evidence  to  show 
that  in  most  instances  lip  carcinomata  are  much  less  virulent.  Possibly 
an  exception  should  be  made  of  cases  of  indurating  carcinomata  of  the 
lip  in  young  people,  persons  under  forty  or  forty-five  years ;  here  the 
lymphatic  excision  should  be  as  radical  as  for  carcinoma  of  the  tongue. 

In  carcinoma  of  the  face  and  mouth  it  is  usually  not  practical  to 
remove  all  of  the  lymphatic  ducts  between  the  growth  and  the  first 
group  or  nodes,  but  fortunately,  secondary  infection  rarely  occurs  in 
these  ducts.  In  the  neck  the  ducts,  as  well  as  the  glands,  should  be 
removed,  if  for  no  other  reason  than  that  by  so  doing  all  glands  will  be 
excised. 

In  the  excision  of  the  primary  focus,  conservatism  should  have  little 
place.  When  one  is  tempted  to  spare  tissue,  he  has  but  to  think  of  a 
few  cases  he  has  seen  in  the  end  stages  of  mouth  carcinoma  to  steel  him 
to  the  safer  course  (Fig.  .SS9).  In  dealing  with  a  carcinoma  of  the  lip, 
the  surgeon  had  best  forget  he  is  dealing  with  a  lip  and  think  only  of  the 
growth.     In  the  slow-growing  flat  ulcers  of  older  persons,  he  may  con- 


CANCER  OF  THE  LIP. 


477 


tent  himself  with  an  excision  that  runs  8  or  10  nnlHmcters  to  each  side 
of  the  evident  disease,  prolonging-  the  excision  for  3  or  more  centimeters 
in  the  direction  of  the  lymph  streams.  In  the  more  rapidly  growing, 
indurating  variety,  the  incision  had  best  be  made  at  least  2  centimeters 
from  its  borders.  If  the  growth  has  run  on  the  cheek  or  upper  lip,  it 
should  be  treated  in  the  same  way.  If  it  has  encroached  upon  the  gum 
apparently  involving  only  the  superficial  tissues,  these  are  to  be  re- 
moved, and  the  bone  sawed  or  bitten  away  down  to  below  the  bottom  of 
the  tooth  sockets.  If  the  induration  is  deep  or  if  the  teeth  are  loose, 
showing  the  tooth .  sockets  to  be  frankly  involved,  then  a  section  of  the 
whole  thickness  of  the  jaw-bone  should  be  removed  as  part  of  a  block 


Fig.  389.  Sbowing  a  patient  in  whom  one  half  of  the  lower  jaw  and  cheek  was  re- 
moved to  get  rid  of  an  inoperable  carcinoma  of  the  mouth,  resulting  from  a  carcinoma 
of  the  lip.  Several  unsuccessful  operations  had  been  done  on  the  lip  and  mouth.  The 
patient  was  made  much  more  comfortable  by  the  removal  shown,  and  the  growth  did  not 
recur  in  the  mouth. 

incision.  (See  Excisions  of  the  Lower  Jaw.)  If  the  involvement  is 
of  the  upper  jaw,  then,  with  a  sharp  chisel,  a  part  of  the  maxilla  is  to 
be  removed.  (See  Excisions  of  the  Maxilla.)  In  every  instance  the 
whole  mass  is  to  he  removed  in  one  block.  The  incisions  should  he  all 
outlined  hefore  the  cutting  is  hegnn  in  any  part. 

Excision  of  Grovi^ths  and  Ulcers  of  Doubtful  Character. — Warts, 
persistent  papules,  or  exfoliating  patches  should  be  removed  bv  a 
V-shaped  incision,  through  the  thickness  of  the  lip,  that  extends  at  least 
j/2  centimenter  to  each  side  of  their  base.  The  incision  is  first  outlined, 
and  the  sides  of  the  V  should  be  bowed  somewhat  outward,  as  this  will 
lessen  the  subsequent  defect,  due  to  scar  contraction  (Figs.  228  and  229). 
The  lip  is  then  injected  with  a  1  per  cent  novocain,  with  andrenalin,  so- 


478  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Iiition,  and  grasped  on  the  outer  side  of  each  mark  with  artery  clamps 
held  by  an  assistant,  but  not  locked.  The  forceps  will  control  the 
bleeding  and  steady  the  lip.  The  center  of  the  base  of  the  wedge  to 
be  excised  is  grasped  with  a  vulsellum  forceps  in  the  hand  of  the  sur- 
geon ;  the  excision  is  then  made  with  a  sharp  knife  or  with  sharp  scis- 
sors. Hemorrhage  is  controlled  by  the  sutures,  but  they  are  not  to  be 
drawn  tight.  If,  after  suturing,  there  is  still  oozing,  an  extra  through- 
and-through  suture  may  be  drawn  tight,  the  latter  to  be  removed  in 
six  or  twelve  hours.     The  specimen  should  be  examined  microscopically. 

Excision  of  Indolent  Carcinomatous  Ulcers. — This  may  be  done 
by  a  V-shaped  incision  made  1  centimeter  on  each  side  of  the  base  of 
the  ulcer.  If  the  ulcer  is  near  the  corner  of  the  mouth,  the  excision 
shown  in  Chap.  XIX  may  be  made.  At  this  or  a  subsequent  time, 
the  glands  are  to  be  removed  according  to  the  plan  to  be  outlined.  If 
the  gland  operation  is  to  be  postponed  to  a  subsequent  sitting,  the  lip  ex- 
cision may  be  done  under  a  local  anesthetic,  but  the  incisions  should  be 
outlined  with  the  point  of  a  knife  before  the  lip  is  infiltrated  with  the 
anesthetic  solution. 

Excision  of  Indurating  Carcinoma  of  the  Lip. — Unless  of  ex- 
ceedingly slow  growth,  the  greater  part  of  the  lower  lip  with  the  soft 
tissues  covering  the  chin  should  be  removed.  Figs.  224  to  235  show 
several  plans  of  excision  according  to  the  size  and  location  of  growth.) 

The  operation  on  the  primary  growth  may  be  done  at  the  same  time 
as  the  excision  of  the  lymph  nodes,  or  the  latter  may  be  done  at  a 
subsequent  sitting.  If  both  are  to  be  done  together,  it  is  our  preference 
to  operate  on  the  neck  first,  stop  all  hemorrhage,  and  repair  the  neck 
before  invading  the  mouth.  In  this  way  less  infectious  material  is 
carried  into  the  neck  wound. 

Typical  Operation  for  an  Early  Indurated  Carcinoma  of  Lower 
Lip. — In  the  operation  about  to  be  described,  a  part  of  the  platysma 
myoides  muscle  and  subcutaneous  fat  is  removed  with  the  mass,  not 
because  they  are  necessarily  involved,  but  because  certain  nodes  lie 
superficial  to  the  muscle.  Below  the  level  of  the  hyoid  bone  the 
platysma  muscle  is  to  be  retained;  and  in  operations  that  require  the 
raising  and  transplantation  of  large  flaps  from  the  neck,  the  platysma 
muscle  is,  where  possible,  to  be  included  with  the  flap  to  insure  its 
nourishment.  Then  care  must  be  exercised  to  make  the  plane  of  cleav- 
age immediately  subjacent  to  the  platysma,  so  as  not  to  include  any 
of  the  lymphatic  nodes  which  accompany  the  external  jugular  vein. 

The  patient  is  placed  in  a  recumbent  or  semisitting  position,  with  the 
head  thrown  slightly  back,  so  as  to  give  good  access  to  the  upper  part 
of  the  neck.  An  incision  is  outlined  with  the  point  of  the  knife,  run- 
ning along  the  lower  border  of  the  jaw  from  angle  to  angle,  and  2^2 


CANCER  OF  THE  LIP.  479 

centimeters  downward  and  backward  on  the  neck  on  either  side  (Fig. 
390).  Next,  tbe  sterile  clotlis  are  so  pinned  in  place  as  not  to  obstruct 
the  view  of  the  neck.  The  incision,  outlined,  is  made  down  to  the 
platysma.  The  flap,  including  little  more  than  the  skin,  is  dissected 
downward  to  the  dotted  line.  This  dotted  line  crosses  the  middle  of 
the  neck  at  the  upper  border  of  the  thyroid  cartilage.  The  skin  flap 
is  raised,  and  the  platysma  and  deep  cervical  fascia  are  incised  along 
the  dotted  line.  This  incision  should  also  cut  the  external  and  anterior 
jugular  veins,  which  are  to  be  caught  with  forceps.  The  proximal 
portions  of  these  veins  are  to  be  at  once  ligated.  A  flap  containing  the 
superficial  fascia,  the  platysma  muscle,  and  superficial  layer  of  the  deep 
cervical  fascia  is  now  dissected  upward,  displaying  the  fibers  of  the 
anterior  part  of  the  sternomastoid,  omohyoid,  and  sternohyoid  muscles. 
As  there  are  intermuscular  processes  of  fascia,  running  from  the  deep 
surface  of  the  cervical  fascia  between  all  of  these  muscles,  the  dissec- 


Pig.  390.  Submental  incision  for  cleaning  out  the  submental,  submaxillary,  and  su- 
perior deep  cervical  lymphatic-bearing  tissue.  The  dotted  lines  show  the  extent  to 
which  the  flap  is  freed. 

tion  must  be  made  with  a  knife  or  dissecting  scissors.  As  the  dissection 
proceeds,  the  mass  of  tissue  that  is  being  removed  is  drawn  somewhat 
forcibly  away  from  the  deep  structures  of  the  neck,  which  puts  the 
tissues  on  tension.  By  catching  vessels  before  cutting  them  and  not 
working  into  pockets,  the  inaccessible  bleeding  is  avoided.  Beneath 
the  anterior  border  of  the  sternomastoid,  the  carotid  sheath  is  displayed. 
At  the  hyoid  bone  the  cervical  fascia  is  attached  and  will  have  to  be 
freed;  above  this  the  stylohyoid  muscle,  the  tendon  of  the  digastric 
muscle,  and  the  mylohyoid  muscle  come  into  view.  As  the  dissection 
is  continued  upward,  the  submaxillary  salivary  glands  are  included  in 
the  mass  to  be  removed  (Fig.  391). 

In  removing  the  submaxillary  salivary  gland,  the  facial  vein  is  di- 
vided at  the  lower,  external  part  of  the  gland ;  the  intraoral  part  of  the 
gland  is  cut  just  where  it  disappears  around  the  posterior  border  of  the 
mylohyoid;  the  facial  artery  is  cut  at  the  lower  border  of  the  jaw-bone, 
and  again  as  it  enters  the  gland  from  under  the  posterior  belly  of  the 


480 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


digastric  muscle.  Here  the  artery  is  cut  close  to  its  origin  from  the 
external  carotid,  and  had  best  be  tied  with  silk.  In  cutting  these  vari- 
ous vessels  and  the  intraoral  part  of  the  gland,  they  are  first  doubly 
caught  with  forceps,  cut,  and  then  ligated.  With  the  submaxillary 
glands  is  also  removed  all  of  the  tissue  covering  the  anterior  bellies  of 
the  digastric  muscles.  In  this  way  the  removal  of  the  submental  and 
submaxillary  nodes  is  made  certain.     We  have  observed  that  submental 


Fig.  391.  Showing  tlie  dissection  of  tlie  upper  part  of  tlie  neck  after  tlie  removal 
of  the  lymphatic-bearing  tissue  of  the  submental  submaxillary  and  superior  deep  cervical 
regions. 


nodes  may  occur  on  the  upper  surface  of  the  anterior  belly  of  the  di- 
gastric near  the  median  border. 

The  smaller  vessels  of  the  neck,  which  have  been  caught  during 
the  operation,  are  now  tied.  Unless  the  condition  of  the  patient  contra- 
indicates,  the  superior  deep  cervical  glands  should  be  removed  on  both 
sides.  The  sternomastoid  muscle  is  retracted,  and  the  outer  ends  of 
the  cutaneous  incision  may,  if  necessary,  be  extended  downward;,  but 
these  spaces  should  not  be  invaded  in  a  haphazard  manner,  for  the  scar 
which  results  from  opening  them  will  complicate  a  secondary  operation. 
If  the  patient  is  not  in  the  best  of  condition,  and  an  operation  on  the 


CANCER  OF  THE  LIP.  481 

deep  cervical  glands  is  indicated,  it  had  best  be  postponed  to  a  later 
time.  If  in  any  place  nodes  are  adherent  to  muscle  or  skin,  this  should 
be  included  in  the  excision. 

The  dissection  of  the  neck  having  been  completed,  rubber  dam 
drains  are  inserted  through  several  stab  vi^ounds  at  the  lower  border  of 
the  dissection,  and  are  sutured  to  the  skin.  If  the  deep  cervical  glands 
have  been  removed,  these  spaces  are  to  be  drained  at  their  upper  and 
lower  ends  by  rubber  dam  strips  which  are  brought  out  through  stab 
wounds.  The  upper  drains  are  useful  when  the  patient  is  in  the  re- 
cumbent position.  All  bleeding  having  been  secured,  the  gland  mass 
which  has  been  dissected  from  the  neck  is  drawn  upward,  and  the  skin 
flap  laid  in  place,  and  by  its  facial  lining  is  sutured  to  the  soft  tissues 
at  the  lower  border  of  the  jaw  by  a  continuous  catgut  suture,  which  is 
so  placed  as  not  to  prevent  the  cutaneous  borders  from  being  properly 
sutured  later.  Next,  a  thickly  folded  wet  bichlorid  or  alcohol  towel 
is  laid  between  the  skin  of  the  neck  and  the  gland  mass,  and  held  at 
the  lower  border  of  the  jaw  by  several  tenaculum  forceps.  This,  with 
the  suturing  of  the  upper  border  of  the  skin  flap  to  the  muscles  just 
below  the  jaw,  is  to  prevent  infection  of  the  neck  wound  from  the 
mouth.  Returning  to  the  cancerous  mass,  the  protective  cloth  covering 
the  face  and  chin  is  removed.  The  primary  cancerous  area  is  excised, 
removing  the  tissues  in  front  of  the  chin,  down  to  the  periosteum.  It  is 
well  to  include  with  the  excision  the  fat  tissue  of  the  cheek  on  each  side 
for  2  centimeters  above  the  lower  border  of  the  jaw ;  in  this  way  the 
buccal  nodes  which  might  be  infected  will  be  removed.  If  other  struc- 
tures are  involved,  they  are  included  (Chap.  XIX),  and  the  whole 
block  with  the  glands  is  removed  in  one  mass. 

The  repair  of  the  lip  is  to  be  made  as  outlined  in  Chap.  XIX,  and 
a  rubber  dam,  leading  to  the  space  in  front  of  the  body  of  the  jaw,  is 
to  be  inserted  at  several  points  on  each  side  along  the  transverse  incision, 
which  is  to  be  closed  with  deep  interrupted  silkworm-gut  sutures. 

If  the  alveolus  and  gum  of  the  anterior  part  of  the  lower  jaw  has 
been  removed,  the  mucous  lining  of  the  floor  of  the  mouth  is  to  be 
sutured  across  the  bone  to  the  mucous  lining  of  the  new  lip.  The 
submucous  space  is  to  be  drained  with  a  strip  of  thin  rubber  dam  led 
out  through  the  transverse  incision.  If  it  is  a  squamous  cell  cancer  of 
the  upper  lip,  the  latter  is  removed;  then  the  operation  on  the  neck  is 
done  as  just  described.  In  either  case  the  carcinoma  and  lip  may  be 
removed  first,  and  the  glands  of  the  neck  removed  as  a  secondary  oper- 
ation. But  on  theoretical  grounds,  it  does  not  seem  to  us  good  surgery 
to  remove  the  glands  before  the  primary  carcinoma;  for  in  this  case 
cancer  cells,  or  the  agency  of  cancer,  might  enter  the  wound  through 
the  cut  ends  of  the  lymphatic  ducts.     The  sutures  should  control  the 


482  SURGERY  OF  THE  MOUTH  AND  JAWS. 

bleeding ;  and  no  dressing-,  other  than  a  dusting  powder  or  a  10  per  cent 
colloidal  silver  solution,  is  applied  to  the  face  wound,  but  the  neck  is 
well  padded  with  gauze  and  bandaged  fairly  firm  to  obliterate  dead 
spaces.  This  obliteration  of  spaces  by  pressure  is  extremely  important. 
The  patient  should  sit  up  within  a  few  hours  after  the  operation  and 
be  allowed  to  get  out  of  bed  as  soon  as  practicable. 

Operation  for  Carcinoma  of  the  Lower  Lip  Where  Repair  is  to 
be  Made  with  Flaps  from  the  Neck. — In  extensive  carcinoma  of  the 
lower  lip,  where  the  excision  has  to  extend  beyond  the  angles  of  the 
mouth,  in  order  to  make  proper  repair,  a  different  procedure  will  have 
to  be  adopted.  The  one  here  presented  is  somewhat  patterned  after  the 
operation  of  Dowd.  The  incision  at  the  lower  limit  of  the  carcinoma  field 
is  outlined,  and  also  one  from  the  middle  of  this  to  the  upper  border  of 
the  thyroid  cartilage.  From  here  the  incision  sweeps  downward  and 
then  outward  to  the  outer  border  of  the  sternomastoid  muscle  and  then 
upward  for  a  short  distance  (Fig.  234).  The  protective  cloths  are 
clamped  in  place  with  tenaculum  forceps  or  safety  pins,  and  the  incision 
is  made.  Beginning  above,  the  midpart  of  the  upper  transverse  incision 
is  carried  to  the  bone  in  such  a  way  as  not  to  open  the  mouth  cavity. 
Next,  the  vertical  and  lower  transverse  incisions  are  made.  Above  the 
hyoid  bone  the  platysma  is  left  in  contact  with  the  gland  mass  to  be  ex- 
cised. Below  the  hyoid  bone  the  platysma  is  raised  with  the  skin  flaps. 
The  subcutaneous  tissues  below  the  chin,  the  lymph-bearing  tissue  of 
the  front  of  the  neck,  and  the  submaxillary  glands  are  removed  as  out- 
lined in  the  previous  operation.  But  it  is  not  practical  to  remove  the 
deep  cervical  nodes,  as  they  are  not  freely  accessible  in  their  upper  part. 
If  these  are  to  be  removed,  it  should  be  done  at  a  subsequent  sitting, 
after  the  flaps  that  form  the  new  chin  and  lips  have  acquired  a  good 
blood  supply  in  their  new  position,  so  that  they  will  not  suffer  from  an 
incision  made  at  their  base.  The  operation  in  the  neck  having  been 
completed  and  rubber  dam  drainage  having  been  inserted  at  several 
points  along  the  lower  and  outer  borders  of  the  wound  (Fig.  335),  the 
head  is  tilted  slightly  forward,  and  the  flaps  are  rotated  upward  until 
there  is  considerable  more  tissue  than  is  immediately  needed  for  the 
construction  of  the  new  lip.  This  lip  will  be  without  mucous  lining  and 
will  later  contract  considerably.  If  it  is  found  that  there  is  not  suffi- 
cient tissue  to  bring  these  flaps  high  enough  up  on  the  face,  then  the 
sutures  of  the  lower  transverse  wound  will  have  to  be  cut,  and  the  defect 
remaining  in  this  part  of  the  neck  will  have  to  be  filled,  either  with  the 
Thiersch  grafts  or  by  flaps  slid  from  lower  on  the  neck.  The  flaps  in 
their  new  position  are  sutured  at  their  deep  surface  by  a  continuous 
catgut  suture  to  the  muscles  just  at  the  lower  border  of  the  jaw  and 
chin.     The  catgut  used  for  this  purpose  should  be  a  double  strand  of  a 


CANCER  OF  THE  LIP.  483 

good  20-day  variety.  Further  security  may  be  had  by  fastening  these 
flaps  to  the  bone  with  one  or  two  tacks.  The  neck  is  now  protected 
with  several  layers  of  a  wet  bichlorid  towel.  The  upper  protective  cloth 
is  removed,  and  after  excising  the  primary  growth,  the  repair  is  made 
as  outlined  (Figs.  234  and  235).  If  the  alveolar  process  of  the  jaw  has 
been  removed,  the  mucous  lining  of  the  floor  of  the  mouth  is  to  be  su- 
tured to  the  deep  surface  of  the  new  lip,  and  the  submucous  space  is  to 
be  drained  by  strips  of  rubber  dam,  let  in  through  cutaneous  stab  wounds. 
If  sufficient  tissue  has  been  obtained,  the  new  lip  will  be  much  too  long 
and  very  loose,  but  subsequent  contraction  will  correct  this.  Any  fitting 
of  these  flaps  that  is  done  should  in  no  way  shorten  the  length  of  the 
new  lip.  If  by  any  chance  it  should  eventually  prove  to  be  too  long, 
this  fault  is  very  easily  corrected. 

An  important  point  to  bear  in  mind  in  these  and  in  all  cancer  oper- 
ations is:  That  the  man  who  undertakes  a  primary  operation  on  a  case 
fitted  for  radical  treatment  assumes  a  great  responsibility;  and  unless 
he  does  his  work  correctly  and  thoroughly,  he  does  his  patient  harm. 
In  most  cases  the  primary  growth  and  the  submental,  submaxillary,  and 
deep  superficial  cervical  lymph  nodes  can  all  be  removed  at  one  or  sev- 
eral properly  planned  primary  operations;  but  to  work  in  the  dense 
scar  that  remains  after  the  first  operation  is  extremely  tedious  and 
difficult,  and  it  is  at  best  guesswork.  If  the  neck  has  been  invaded  and 
the  operation  for  the  primary  growth  is  not  a  success,  the  condition  is 
still  more  hopeless;  for  the  lymph,  seeking  new  channels,  is  very  apt 
to  cause  infection  of  nodes  which  are  much  less  accessible  to  surgical 
interference. 

Operations  for  secondary  infections  in  regions  which  have  not  been 
disturbed — for  instance,  the  removal  of  the  deep  cervical  nodes  after 
there  has  been  a  proper  cleaning  out  of  the  submaxillary  and  submental 
regions — may  be  undertaken  with  a  reasonable  amount  of  confidence, 
but  operations  in  a  region  that  has  been  unsuccessfully  invaded  are  most 
likely  to  prove  unsuccessful. 

Before  closing  this  chapter,  it  is  well  to  say  a  word  in  regard  to 
unilateral  versus  bilateral  removal  of  the  lymph  nodes  in  lip  carcinoma. 
In  very  early  cases  situated  well  toward  one  corner  of  the  mouth,  it 
may  be  proper  to  do  a  unilateral  neck  operation,  but  clinical  illustrations 
of  early  bilateral  infection  of  the  lymph  nodes  from  a  unilateral  focus 
are  so  common,  that  the  safer  plan  is  to  make  a  bilateral  excision  of  at 
least  the  submaxillary  and  submental  nodes  in  all  cases. 

PROGNOSIS. 

Carcinoma  of  the  lip  gives  the  best  operative  result  of  any  form  of 
carcinoma,  and  it  is  probably  perfectly  fair  to  state  that  the  cures  should 
be  above  75  per  cent. 


CHAPTER  XXXIV. 
TUMORS  AND  CYSTS  OF  THE  FLOOR  OF  THE  MOUTH. 

With  the  exception  of  ranula,  affections  of  the  saHvary  glands  and 
their  ducts  are  not  included  in  this  chapter. 

OBSTRUCTION  CYSTS  OF  THE  MUCOUS  GLANDS. 

Retention  cysts  of  the  muciparous  glands  may  be  found  on  the  inner 
surface  of  the  lips  and  on  the  cheek  along  the  line  of  occlusion  where 
they  may  be  caught  between  the  teeth.  Occasionally  they  are  found 
along  the  edge  of  the  upper  surface  of  the  tongue.  (Their  appearance 
and  treatment  were  discussed  in  the  Chapter  on  the  Lips,  p.  471.) 

A  more  striking  cyst  is  sometimes  observed  under  the  tip  of  the 
tongue,  due  to  the  distention  of  a  duct  in  the  glands  of  Blandin.  They 
may  attain  considerable  size,  are  of  the  same  bluish-gray  color  as  other 
mucous  cysts,  and  are  to  be  treated  by  excision  of  the  gland. 

RANULA. 

This  is  a  rather  general  term  applied  to  chronic  benign  cysts  of  the 
floor  of  the  mouth,  due  to  obstruction  of  a  duct  or  of  a  mucous  or  sali- 
vary gland.  There  has  been  much  discussion  as  to  the  true  nature  of  the 
cyst.  Nevertheless  either  the  anatomical  relations  or  histologic  structures 
of  the  cysts  that  occur  in  the  anterior  part  of  the  floor  of  the  mouth  would, 
it  seems  to  us,  limit  the  site  of  origin  of  a  ranula  to  one  of  three  struc- 
tures :  the  incisive  glands  of  Suzanne  and  Merkel,  the  sublingual  sali- 
vary glands,  or  one  of  Bochdalek's  glands.  Probably  the  most  common 
misstatement  made  in  regard  to  them  is  that  they  are  due  to  obstruction 
of  the  submaxillary  duct.  This  is  denied  by  every  careful  observer,  for 
Wharton's  duct  has  always  been  found  at  least  partially  patent,  when 
examined  in  the  presence  of  typical  ranula.  Obstruction  of  this  duct 
gives  entirely  different  symptoms.  It  cannot  be  stated  that  a  complete 
obstruction  of  the  submaxillary  duct  could  not  cause  a  cyst  in  the  floor 
of  the  mouth ;  but  as  the  obstruction  is  then  in  the  common  excretory 
duct,  the  whole  submaxillary  gland  shares  in  the  distention,  and  cysts 
arising  in  the  intraoral  part  of  the  submaxillary  gland  bulge  downward 
toward  the  neck.  Whether  or  not  cysts  of  Blandin's  glands  are  to  be 
included  under  ranula  is  rather  a  matter  of  individual  classification. 
The  term  has  been  commonly  taken  to  mean  a  cyst  in  the  floor  of  the 
mouth ;  and  cysts  of  these  apical  glands  are  usually  confined  to  the  under 

484 


TUMORS  AND  CYSTS  OF  THE  FLOOR.  485 

surface  of  the  tongue,  and  when  the  tongue  is  protruded,  the  cyst  moves 
with  it.  If  we.  define  ranula  as  a  cyst  of  the  floor  of  the  mouth,  then  a 
cyst  of  an  apical  gland  will  seldom  come  under  this  heading. 

The  rarest  form  of  ranula  is  that  which  arises  in  the  midline,  just 
behind  the  incisor  teeth,  and  is  credited  to  the  incisive  glands.  A  ranula 
is  much  more  commonly  lateral  in  its  origin,  but  as  it  grows,  it  crosses 
the  midline  and  may  be  notched  by  the  frenum.  Certain  ranulae  are 
lined  with  ciliated  epithelium,  which  in  the  mouth  occurs  only  in  the 
thyroglossal  tract  or  its  offshoots — as  the  glands  of  Bochdalek.  That 
obstruction  of  an  excretory  duct  of  the  sublingual  gland  is  the  most 
common  origin  of  ranula  is  almost  generally  admitted.  According  to 
Baker,  quoted  by  Butlin,  it  is  accompanied  by  a  secondary  atrophy  of 
the  remainder  of  the  gland  and  partial  obstruction  of  the  submaxillary 
duct  by  pressure.  Morestin  presents  a  dissection  which  shows  the  lobes 
of  the  sublingual  gland  extending  through  the  mylohyoid  muscle  and 
appearing  upon  its  imder  surface.  This  appears  to  be  an  explanation 
for  certain  ranulae  that  bulge  below  the  chin  in  a  more  marked  manner 
than  would  result  simply  from  pressure  upon  the  upper  surface  of  the 
mylohyoid  muscle. 

A  ranula  is  usually  unilocular,  but  there  is  no  reason  why  it  could 
not  have  a  double  origin. 

Symptoms. — There  is  a  chronic  slow-growing  swelling  in  the 
anterior  part  of  the  floor  of  the  mouth,  situated  immediately  beneath 
the  mucous  membrane,  which  may  be  median,  or  more  on  one  side  than 
the  other.  It  is  of  a  bluish-gray  color,  or  may  be  reddish-gray  from  the 
number  of  small  vessels  that  cover  it.  It  is  often  covered  by  veins.  It 
is  tense  and  fluctuates,  but  does  not  pit  on  pressure.  It  raises  the 
tongue  upward  and,  when  large,  may  cause  considerable  inconvenience 
and  discomfort,  but  it  is  not  painful.  It  rarely  causes  a  prominence 
below  the  chin.  If  ranula  develops  in  childhood,  it  may  cause  con- 
siderable protrusion  and  deformity  of  the  lower  jaw  and  displacement 
of  the  teeth.  Rarely  becoming  infected,  it  causes  extensive  sloughing 
in  the  floor  of  the  mouth.  They  occasionally  rupture  spontaneously, 
but  the  relief  is  only  temporary,  as  the  fistula  closes  and  the  sack  refills. 
Rapidly  developing  cysts  of  the  floor  have  been  termed  acute  ranulae. 
Several  have  been  reported  which  were  due  to  acute  obstruction  of 
Wharton's  duct,  coming  on  while  eating,  in  which  there  was  a  lateral 
swelling  of  considerable  size  and  also  swelling  of  the  submaxillary 
gland ;  in  every  instance  it  was  very  painful.  We  have  seen  one  such 
case  which  was  bilateral.  If  the  sublingual  bursa  described  by  Telleux 
really  exists,  this  might  account  for  some  acute  ranulae,  in  which  case  it 
would  be  a  bursitis,  but  Butlin  denies  the  existence  of  this  bursa.  An 
intermittent  ranula  may  occur,  due  to  a  recurrent  obstruction  of  a  duct. 


486  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Diagnosis. — A  lipoma  in  the  floor  of  the  mouth  might  be  mis- 
taken for  ranula,  as  might  an  angioma ;  but  on  feeling  it,  a  soft,  solid, 
or  readily  collapsible,  blood-vessel  tumor  could  be  distinguished  from 
a  cyst.  Moreover,  the  appearance  of  these  is  usually  dififerent  from 
ranula,  but  Monod  has  reported  a  dermoid  in  the  midline  under  the 
tongue,  which  was  of  a  bluish  color,  and  apparently  fluctuated. 

Dermoids  have  a  doughy  feeling,  and  pit  somewhat  on  pressure. 
Cysts  of  Wharton's  duct  are  fusiform  and  are  accompanied  by  swelling 
of  the  submaxillary  gland. 

Treatment. — Many  small  ranulae  will  disappear  after  opening 
freely  and  swabbing  them  out  with  carbolic  acid  or  tincture  of  iodin, 
but,  besides  being  uncertain  of  result,  this  cannot  be  considered  good 
surgical  practice.  Though  also  uncertain  of  result,  the  passing  of  a 
seton  of  silk  or  twisted  wire  through  the  cyst  and  allowing  it  to  stay 
until  it  falls  out  is  not  open  to  the  more  serious  objections  of  the  first 
method.     Brophy  uses  a  hollow  fenestrated  ring. 

There  are  two  other  ways  in  which  a  ranula  can  be  treated:  com- 
plete excision ;  and  the  removal  of  all  of  its  upper  wall  with  the  super- 
imposed mucous  membrane,  and  then  suturing  the  cut  mucous  edge  to 
the  edge  of  the  cyst  wall.  This  latter  operation  should  be  done  so  that 
the  floor  of  the  cyst  is  completely  exposed  and  there  is  no  overhanging 
edge.  It  is  best  accomplished  by  making  an  opening  into  the  cyst  wall 
and  getting  a  good  hold  upon  the  wall  and  mucous  membrane  with  a 
Halsted  artery  forceps.  Drawing  the  forceps  upward,  the  wall  and 
mucous  covering  are  cut  around  with  a  pair  of  scissors,  curved  upon 
the  flat.  Care  should  be  taken  to  wound  neither  the  submaxillary  ducts 
nor  their  opening.  Hemorrhage  is  controlled  partially  with  artery  for- 
ceps, and  completely  by  a  continuous  buttonhole  suture  of  catgut,  which 
fastens  the  mucous  membrane  to  the  edge  of  the  cyst  floor.  This  oper- 
ation leaves  part  of  the  cyst  wall  to  replace  the  normal  mucous  floor. 
We  believe  that  it  is  good  surgery  to  adopt  this  method  with  very  large 
uncomplicated  cysts,  as  excision  of  a  large  ranula  is  a  serious  operation. 
If  not  successful,  the  extirpation  can  be  done  later.  Except  in  nervous 
people  this  operation  can  be  done  under  novocain-adrenalin  injections. 
The  cysts  can  almost  always  be  excised  from  within  the  mouth,  under 
either  a  local  or  general  anesthetic;  but  it  is  to  be  remembered  that  a 
cyst  of  the  sublingual  gland  will  not  shell  out  and  will  have  to  be  cut 
from  the  remaining  part  of  the  gland.  This  operation  is  done  by  a 
free  transverse,  or  horseshoe-shaped,  incision  of  the  mucous  and  sub- 
mucous tissues  in  front  or  behind  the  openings  of  the  submaxillary  ducts, 
according  to  the  location  of  the  cyst.  By  blunt  dissection,  after  the 
cyst  wall  is  bared,  the  mucous  and  submucous  tissue  is  pushed  backward 
and  forward  until  the  upper  surface  and  sides  of  the  cysts  are  freed. 


TUMORS  AND  CYSTS  OF  THE  FLOOR.  487 

If,  for  want  of  room,  there  seems  to  be  danger  of  rupturing  its  wall, 
it  may  now  be  opened  by  a  free  incision,  to  the  edge  of  which  three 
forceps  are  attached.  With  a  finger  in  the  sac  as  a  guide,  it  is  freed 
by  blunt  dissection  or  by  clipping  with  a  pair  of  blunt-curved  scissors. 
After  removal,  the  sac  should  be  examined,  and  if  missing  in  any  part, 
this  should  be  sought  and  removed. 

If  the  surgeon  is  doubtful  of  having  removed  all  of  the  wall  in  any 
particular  part,  the  edge  of  the  mucous  membrane  should  be  sutured 
around  the  supposed  situation  of  this  piece  of  cyst  wall;  otherwise  the 
cavity  should  be  lightly  packed  with  mildly  antiseptic  gauze  for  a  few 
days,  when  a  mouth  wash  will  be  all  that  is  needed.  Some  large  cysts 
might  be  more  easily  removed  by  an  external  incision,  and  if  the  cyst 
protrudes  through  the  mylohyoid  muscle,  this  is  the  only  way  it  can 
be  approached,  Kiittner  recommends  that  this  approach  be  made  sub- 
mentally,  as  for  removing  a  dermoid  (see  p.  488)  ;  but  if  it  is  necessary 
to  make  an  external  approach,  the  most  satisfactory  way  is  to  divide 
the  lip  and  jaw-bone,  as  in  Kocher's  normal  approach  for  excision  of 
the  tongue  (see  p.  588).  If,  in  removing  the  tumor  from  below,  the 
mucous  membrane  of  the  floor  is .  cut  through,  this  should  be  imme- 
diately sutured,  and  the  submental  drainage  should  not  be  removed 
until  active  suppuration  ceases. 

DERMOID  CYSTS. 

Though  dermoids  are  always  congenital,  due  to  an  inclusion  of  the 
epidermis  within  the  tissues  formed  from  the  mesoderm,  still  they  are 
rarely  noticed  at  birth,  and  may  not  be  evident  until  well  past  middle 
life.  The  great  majority  of  them  appear  between  the  tenth  and  twenty- 
fifth  years.  They  consist  of  a  fibrous  capsule  lined  with  stratified 
epithelium,  containing  a  mass  that  may  vary  in  consistency  from  tooth 
paste  to  the  yellow  of  a  hard-boiled  egg.  They  may  contain  hair  or 
other  skin  appendages.  Usually,  as  the  result  of  ill-planned  attempts 
at  their  destruction,  the  cavity  may  be  an  abscess  communicating  with 
the  mouth  or  neck  by  a  fistulous  tract.  As  the  suppuration  never  com- 
pletely destroys  the  epithelial  lining,  the  fistula  persists  and  discharges 
intermittently.  Dermoids,  in  relation  to  the  floor  of  the  mouth,  occur 
in  one  or  two  situations :  in  the  midline  beneath  the  skin  or  between  the 
geniohyoglossi  muscles;  or  laterally  below  the  angle  of  the  jaw.  It 
is  Butlin's  opinion  that  laterally  situated  dermoids,  which  do  not  repre- 
sent the  remains  of  a  branchial  pouch,  were  once  median  and  have 
shifted  their  position  during  development.  It  is  possible  that  a  dermoid 
occurring  above  the  epiglottis  may  have  originally  had  a  more  forward 
position  (Fig.  392).  Inclusion  at  the  midline  could  occur  only  at  the 
time  of  fusion  of  the  mandibular  tubercles. 


488 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


The  dermoid  may  attain  such  a  size  that  the  site  at  which  it  started 
to  grow  can  no  longer  be  determined.  When  small,  they  usually  pro- 
trude downward  below  the  chin,  but  may  bulge  upward  into  the  mouth, 
in  which  case  they  appear  as  a  yellowish  mass  beneath  the  mucous 
membrane.  When  very  large,  a  dermoid  may  press  the  tongue  upward 
and  backward,  and  even  cause  dyspnea.  They  are  to  be  distinguished 
from  ranulae,  which  have  a  bluish  or  reddish-gray  color,  and  when 
sufficiently  large,  ranulae  give  a  distinct  sense  of  fluctuation.  On  bi- 
manual palpation  dermoids  yield  a  doughy  sensation.  They  are  of  slow 
growth,  usually  requiring  some  years  to  attain  any  considerable  size. 
In  this  they  differ  from  most  sarcomata,  and  they  differ  from  all  soft 
solid  growths,  including  lipomata,  in  the  doughy  feeling  that  can  usually 
be  made  out,  and  in  the  fact  that  unless  very  tense  they  pit  on  pressure. 
A  dermoid,  situated  deep  in  the  muscles  near  the  hyoid  bone,  might  be 


-Geniohyoglossus  muscle, 
-Jaw-bone. 
..Geniohyoid  muscle. 
..Mylohyoid  muscle. 


Hyoid  bone. 


Fig.  392.  Diagram  showing  the  locations  of  median  dermoids  in  the  floor  of  the 
mouth. — After  Butlin. 

difficult  to  distinguish  from  a  thyroid  tumor  or  cyst  in  this  situation 
(Fig.  392). 

The  treatment  of  dermoids  is  complete  excision.  If  the  mass  is 
situated  immediately  beneath  the  mucous  membrane,  it  can  be  removed 
from  within  the  mouth  by  a  free  incision  and  blunt  dissection,  but 
otherwise  it  is  preferable  to  approach  it  from  below.  It  is  abso- 
lutely necessary  to  remove  the  whole  of  the  epithelial  wall.  When 
approached  externally,  perfectly  free  access  and  a  clear  view  of  the 
tumor  can  be  obtained.  Further,  the  wound  can  be  kept  aseptic,  the 
bleeding  is  easily  controlled,  and  a  properly  placed  skin  incision  will 
leave  no  perceptible  scar. 

For  a  medianly  placed  cyst,  a  transverse  submaxillary  incision  is 
made  from  near  the  angle  of  the  jaw  on  each  side,  and  a  little  in  front 
of  the  body  of  the  hyoid  bone.  This  incision  cuts  through  the  platysma 
muscle,  and  the  flaps  are  retracted  so  that  the  muscles  forming  the  floor 


TUMORS  AND  CYSTS  OF  THE  FLOOR. 


489 


of  the  mouth  are  exposed  from  the  chin  to  hyoid  bone.  At  the  extrem- 
ities of  the  incision  the  submaxillary  glands  will  be  uncovered.  The 
median  raphe  of  the  mylohyoid  muscle  is  incised,  and  the  two  halves  of 
this  muscle  and  the  geniohyoid  are  drawn  apart  with  retractors.  It  is 
probable  that  the  cyst  will  come  into  view  as  soon  as  the  mylohyoid  is 
incised,  and  it  is  to  be  freed  by  blunt  dissection.  It  may  be  attached  to 
the  symphysis  of  the  jaw  or  to  the  body  of  the  hyoid  by  fibrous  septa 
(Fig.  393). 

For  a  large  cyst  extending  up  into  the  anterior  part  of  the  floor, 
one  or  both  sides  of  the  mylohyoid,  with  the  corresponding  geniohyoid. 


Fig.  393.  Sublingual  cy.st  approached  through  a  transverse  suibmaxillary  skin  in- 
cision, and  a  vertical  incision  through  the  mylohyoid  muscle.  (Error — tliyr.  cart,  should 
be  hyoid  bone.) 

may  be  cut  fairly  close  to  the  jaw-bone,  but  not  too  close  to  prevent  its 
subsequent  suture.  Before  both  geniohyoid  are  cut,  a  ligature  should 
be  passed  through  the  tongue  to  prevent  dyspnea  by  backward  displace- 
ment of  the  tongue  and  hyoid. 

If  the  cyst  is  situated  farther  back,  near  the  hyoid  and  bulging 
toward  the  foramen  cecum,  or  oral  pharynx,  the  transverse  incision 
of  the  muscles  should  be  made  just  above  the  hyoid  bone.  The  attach- 
ments of  the  mylohyoid,  the  facial  attachments  of  the  digastrics,  the 
attachments  of  the  geniohyoid  and  geniohyoglossus  may  all  be  cut  just 
above  the  hyoid,  after  securing  the  body  of  the  tongue  by  transfixing  it 
with  a  ligature  within  the  mouth.     Enough  muscle  should  be  left  at 


490  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tached  to  the  hyoid  to  admit  of  subsequent  suturing  of  these  muscles, 
but  the  hypoglossal  nerves  must  not  be  injured.  If  enough  room  is 
not  to  be  gained  in  this  way,  as  may  be  the  case  with  a  suprahyoid 
thyroglossal  duct  tumor,  the  hyoid  bone  may  be  split  in  the  midline 
after  making  a  supplementary  median  skin  incision  in  front  of  the 
larynx.  In  this  way  the  tongue  can  be  separated  into  two  halves  up  to 
its  dorsal  mucous  membrane,  giving  free  access  to  any  median  growth. 
If  the  operation  threatens  to  involve  the  mucosa  of  the  tongue,  the  head 
should  be  held  low  to  prevent  blood  entering  the  larynx.  If  the  cyst 
is  very  large,  it  may  be  tapped  when  it  comes  into  view,  which  will 
facilitate  its  removal  (Fig.  407). 

After  satisfying  one's  self,  by  an  examination  of  the  specimen,  that 
it  has  been  completely  removed,  all  muscles  which  have  been  cut  are 
sutured  with  a  few  interrupted  tannated  gut  sutures.  If  the  hyoid 
bone  has  been  severed,  the  two  halves  may  be  held  in  apposition  by 
tannated  gut  sutures  passed  through  its  fascial  coverings.  A  rubber 
dam  drain  is  placed  in  the  midline,  and  the  platysma  and  skin  are  re- 
approximated.  (For  the  manner  of  outlining  the  incision  and  placing 
protective  cloths  around  a  clean  neck  field,  see  Operation  on  Cervical 
Lymphatics,  p.  597.)  The  rubber  drain  is  to  be  left  in  place  twenty- 
four  to  forty-eight  hours.  If  through-and-through  sutures  have  been 
used,  they  are  to  be  removed  on  the  fourth  day  after  operation,  and  the 
line  of  union  protected  by  one  layer  of  gauze  and  flexible  collodion, 
which  does  not  occlude  the  drainage  opening.  In  removing  the  sutures 
from  a  recent  transverse  wound  in  the  upper  part  of  the  neck,  the  head 
should  not  be  thrown  back,  for  the  wound  may  be  pulled  open. 

For  a  laterally  situated  dermoid,  the  incision,  through  the  platysma 
and  superficial  fascia,  should  extend  from  the  mastoid  process  along  the 
body  of  the  hyoid.  The  superficial  flap  is  drawn  upward  to  expose 
the  field.  The  deep  cervical  fascia  is  incised  at  the  lower  border  of  the 
submaxillary  salivary  gland,  and  the  gland  is  also  drawn  upward,  which 
will  expose  the  mylohyoid  muscle,  beneath  or  behind  which  the  cyst 
can  be  felt  or  seen.  In  incising  the  mylohyoid,  care  should  be  taken 
not  to  wound  the  hypoglossal  nerve,  which  will  be  seen  disappearing 
beneath  the  posterior  border  below  the  cyst.  The  cyst  is  removed,  and 
the  wound  is  treated  as  described  in  the  previous  operation. 

Treatment  of  a  Sinus  Leading  to  a  Suppurating  Dermoid. — The 
sinus  and  the  cyst  should  be  removed.  This  should  not  be  undertaken 
during  an  attack  of  acute  inflammation ;  but  at  this  time  the  pus  may 
be  liberated,  usually  by  a  probe  or  forceps  passed  into  the  blocked  sinus, 
and  a  drain  inserted.  When  the  radical  operation  is  undertaken,  the 
sac  should  be  emptied  as  nearly  as  possible  by  gentle  pressure.  The 
sinus  and  the  sac  are  to  be  dissected  out. 


TUMORS  AND  CYSTS  OF  THE  FLOOR.  491 

BENIGN  TUMORS. 

Various  benign  tumors  are  to  be  excised.  Those  situated  in,  or 
immediately  beneath,  the  mucous  membrane  of  the  floor  are  to  be 
removed  from  within  the  mouth.  More  deeply  situated  tumors  may 
be  approached  from  the  outside,  as  are  dermoid  cysts  (pp.  488,  490). 

MALIGNANT  TUMORS. 

Sarcoma  can  occur  in  either  of  these  situations,  but  the  much  more 
common  tumor  is  carcinoma.  In  the  floor  of  the  mouth  carcinoma  may 
arise  close  to  the  tongue,  in  which  case  it  has  been  supposed  to  be  possi- 
bly a  primary  carcinoma  of  the  sublingual  gland,  or  it  may  be  an  ex- 
tension from  the  tongue.  Carcinoma  may  occur  in  the  outer  part  of 
the  floor  as  an  extension  from  the  jaw.  In  the  cheek  carcinoma  may 
occur  as  an  extension  from  the  lip  or  jaw,  or  may  arise  independently. 
The  latter,  when  on  the  mucous  surface,  are  almost  always  of  the 
indurating,  ulcerating  type.  (For  symptoms  and  course  of  carci- 
nomata,  see  Carcinoma  of  Lips.  Chap.  XXXIII,  Jaws,  Chap.  XXX, 
and  Tongue,  Chap.  XXXVIII.) 


CHAPTER  XXXV. 

AFFECTIONS  OF  THE  SALIVARY  GLANDS  AND  THEIR 

DUCTS. 

The  salivary  ducts  and  glands  are  occasionally  the  seat  of  congenital 
abnormalities ;  congenital  atresia  of  the  duct  has  caused  cystic  formation. 
The  glands  may  be  found  displaced  from  their  normal  site,  or  the  duct 
openings  may  be  in  an  abnormal  position.  Kuttner  cites  a  case  of 
Gherini's,  of  a  young  girl  who  had  two  small  openings  a  little  above 
the  sternum  and  median  to  the  sternomastoid  muscles.  Saliva  exuded 
from  the  fistulas,  and  injection  of  a  colored  fluid  into  the  fistulse  caused 
the  colored  fluid  to  appear  at  the  sublingual  caruncle.  It  is  possible 
in  this  case  that  there  is  a  communication  between  Wharton's  duct  and 
a  branchial  fistula  on  each  side. 

INFLAMMATION  OF  THE  LARGER  DUCTS. 

Formerly  it  was  rather  generally  accepted  that  most  infections  of 
these  glands  were  of  a  metastatic  origin,  but  now  there  is  considerable 
evidence  to  show  that  most,  if  not  the  vast  majority,  of  these  occur 
through  their  excretory  ducts.  Even  in  the  so-called  secondary  infec- 
tions of  the  salivary  glands,  it  is  probable  that  the  infection  is  acci- 
dental, occurring  from  the  mouth  through  the  duct. 

The  most  common  instance  of  inflammation  of  a  duct  is  in  connec- 
tion with  a  stone  or  a  foreign  body;  but  a  duct  may  become  inflamed 
without  the  presence  of  a  foreign  body  or  a  stone.  In  the  early  stages 
of  an  extensive  inflammation,  the  mouth  of  the  duct  will  be  found  open, 
and  the  mucous  lining  everted.  If  the  duct  is  squeezed,  a  drop  of  pus 
may  exude.  When  the  inflammation  is  dependent  on  the  presence  of 
a  stone  or  other  foreign  body,  recovery  usually  follows  quickly  after  the 
removal  of  the  mechanical  irritant.  When  the  inflammation  develops 
in  the  absence  of  any  mechanical  irritant,  it  is  often  of  a  chronic,  per- 
sistent character,  and  there  is  a  dilatation  of  the  duct  and  a  thickening 
of  its  walls.  The  tube  may  become  so  patent  that  air  can  enter  it.  It 
is  supposed  that  this  phenomenon  has  been  observed  most  commonly  in 
glass-blowers. 

Besides  those  symptoms  already  noted,  there  often  occurs  during 
eating  the  ordinary  symptom  of  acute  obstruction  due  to  a  foreign 
body  in  the  fluct  (see  p.  TjOD  ).  This  is  due  to  a  plug  of  mucus  or  fibrin. 
Secondarily,  the  gland  may  become  permanently  enlarged.    Usually 

492 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  493 

the  result  of  treatment  in  chronic  simple  inflammation  of  the  ducts 
is  not  particularly  satisfactory,  but  in  the  earlier  cases  and  in  those 
giving  obstructive  symptoms,  help  can  be  afforded.  The  duct  should 
be  sounded  to  exclude  a  foreign  body;  this  being  absent,  the  duct  can 
be  irrigated  once  a  day  v^^ith  a  5  per  cent  solution  of  argyrol  or  colloidal 
silver,  or  a  1 :2000  solution  of  potassium  permanganate.  The  injec- 
tions are  best  made  with  a  long  probe-pointed  needle.  In  older  cases 
the  gentle  dilatation  of  the  duct  with  a  sound  before  injection  might  be 
helpful.  In  all  cases,  however,  the  injections  should  be  made  gently, 
and  it  should  be  seen  that  the  fluid  returns  freely. 

If  there  is  a  blocking  or  stricture  of  the  duct  at  or  near  the  orifice, 
this  may  be  relieved  by  slitting  the  duct  with  probed  scissors  or  on  a 
grooved  director.  The  inflammations  that  follow  injuries  or  accom- 
pany stones  and  foreign  bodies  may  be  of  any  grade,  from  a  subacute 
mild  suppuration  to  virulent  spreading  phlegmon,  but  are  usually  of 
the  former  grade. 

EPIDEMIC  PAROTITIS  (MUMPS). 

Although  commonly  called  parotitis,  the  disease  often  affects  the 
other  salivary  glands  and  may  even  affect  these  without  involvement  of 
the  parotid.  It  is  an  acute,  contagious,  non-suppurating  infection  of 
one  or  several  glands  and  their  ducts,  preceded  by  a  stomatitis.  It  may 
become  epidemic  in  barracks,  etc.,  but  most  commonly  affects  children. 
At  first  one  gland  is  involved,  usually  the  left  parotid,  the  other  as  a  rule 
being  infected  later.  The  skin  over  the  swelling  becomes  edematous. 
This  swelling  may  be  rather  extensive,  and  there  is  always  moderate 
fever.  The  disease  begins  to  subside  in  about  a  week,  and  all  traces 
of  the  swelling  are  gone  in  from  two  to  four  weeks.  Recovery  almost 
always  follows,  but  in  a  number  of  cases  there  is  an  accompanying 
swelling  of  one  or,  sometimes,  both  testicles,  which  may  be  followed  by 
permanent  atrophy.  Occasionally  it  is  accompanied  by  other  com- 
plications, such  as  oophoritis,  mastitis,  vulvovaginitis,  inflammations 
of  the  urinary  tract  or  of  the  eye  and  ear,  or  encephalon. 

ACUTE   SUPPURATIVE   INFLAMMATION    OF  THE   SUB- 
MAXILLARY AND  SUBLINGUAL  GLANDS  IN 
YOUNG  INFANTS. 

In  the  first  few  weeks  or  months  of  life,  infants  may  be  affected 
by  an  acute  suppurative  inflammation  which  is  accompanied  by  swelling 
of  these  glands,  discharge  of  pus  from  their  ducts,  and  the  formation 
of  intraglandular  abscesses.  In  otherwise  healthy  infants  recovery 
usually  takes  place,  but  the  glands  should  be  opened  as  soon  as  the 
formation  of  confined  pus  is  suspected. 


494  SURGERY  OF  THE  AIOUTH  AND  JAWS. 

SECONDARY  INFECTIONS  AND  SEPTIC  PAROTITIS. 

Acute  septic  infection  of  the  salivary  glands  is  most  commonly 
seen  in  the  parotid.  This  is  often  referred  to  as  a  secondary  or  metas- 
tatic parotid  abscess.  Formerly  it  was  rather  generally  accepted  that  the 
acute  septic  infections  of  these  glands  were  metastatic ;  later  considerable 
evidence  accumulated  to  show  that  most,  if  not  nearly  all,  were  ascend- 
ing infections  of  the  excretory  ducts ;  and  the  fact  that  the  stomata  of 
both  the  submaxillary  and  the  parotid  ducts  are  at  the  apices  of  mucous 
papillae  suggests  that  an  effort  has  been  made  to  protect  them  from 
contamination  caused  by  foreign  bodies  or  fluids  entering  from  the 
mouth.  The  later  work  of  Rosenow  on  infection  of  the  bile-ducts 
must,  however,  make  us  hesitate  before  entirely  condemning  the  meta- 
static idea.  Neither  theory  has  ever  been  demonstrated  beyond  dispute. 
Be  this  as  it  may,  during  the  acute  stage  of  some  infectious  fever,  to- 
ward the  period  of  subsidence,  or  a  few  days  after  some  operation, 
supposedly  more  common  after  operation  on  the  ovaries,  a  swelling 
may  appear  in  one  or  both  parotids ;  less  commonly  in  one  of  the  other 
salivary  glands.  In  the  parotid  the  swelling  is  usually  first  marked  in 
front  of  the  lobe  of  the  ear,  where  the  capsule  is  less  tense,  but  subse- 
quently the  swelling  is  evident  over  the  whole  gland.  In  fulminating 
cases  the  swelling  may  come  up  very  rapidly,  and  the  involvement  of 
the  parotid  be  obscured  by  the  edema  of  the  cheek  and  neck.  The  ap- 
pearance of  the  swelling  is  accompanied  by  fever  and  the  other  ordi- 
nary symptoms  of  septic  infection ;  occasionally  by  discoloration  of 
the  skin,  and  often  there  is  severe  pain  and  tenderness,  most  marked 
over  the  parotid.  These  patients  frequently  present  evidence  of  being 
extremely  ill.  Within  the  mouth  there  is  usually  some  swelling  of 
the  parotid  papilla,  and  at  its  apex  may  usually  be  seen  a  minute, 
dark-red  spot  which  we  have  interpreted  as  being  a  visible  part  of  the 
swollen  mucous  lining  of  the  duct.  The  flow  of  saliva  from  the  duct 
may  be  entirely  suppressed,  or  pus  may  be  squeezed  out.  In  milder 
cases  the  symptoms  may  subside  in  a  few  days  or  go  on  to  localized 
suppuration.  The  infection  is  often  of  a  severe  grade,  however, 
causing  diffuse  phlegmon  of  the  gland,  which  may  spread  to  the  sur- 
rounding tissues.  Even  these  severe  cases  can  usually  be  spared  by 
prompt  treatment,  if  the  infection  is  confined  to  the  parotid ;  but  ful- 
minating, septic  parotitis  is  frequently  but  one  expression  of  a  general 
severe  sepsis  in  a  debilitated  patient,  and  here  treatment  of  the  parotid 
may  do  nothing  more  than  contribute  to  the  comfort  of  the  patient's 
few  remaining  hours. 

Treatment. — In  the  earlier  stages,  ice  should  be  applied.  If  sup- 
puration occurs,  it  will  usually  be  on  the  third  or  fourth  day  and  be 
accompanied  by  an  increase  of  all  symptoms.    This  is  the  proper  time 


AFFECTIONS  OF  THE  SALIVARY  GLANDS. 


495 


for  radical  treatment.  If  specially  tender  or  softened  spots  can  be 
found,  these  nigty  be  opened  by  an  incision  down  to  the  capsule.  A 
round-nosed  conical  artery  forceps  should  then  be  inserted,  but  in 
the  presence  of  severe  symptoms  the  surgeon  should  not  wait  for  defi- 
nite fluctuation,  which,  owing  to  the  tenseness  of  the  capsule,  may 
never  be  evident.     In  such  cases  radical  treatment  may  be  urgently 


Eig.  394.  Exposure  of  the  parotid  gland.  The  oblique  dotted  line  with  its  upper 
forward  curve  shows  the  line  of  incision  which  may  be  extended  down  the  neck  any 
distance.  The  oval  dotted  line  shows  the  posterior  and  inferior  boundary  of  the  gland. 
Note  the  two  branches  of  the  7th  nerve  leaving  the  parotid  gland  at  its  anterior  border ; 
these   should   not  be   injured. 


Fig.  395.     Bilateral  parotid  abscess  following  operation  for  suppurative  appendicitis. 


496 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


necessary  within  twenty-four  hours  after  the  first  appearance  of  symp- 
toms. Here,  in  the  absence  of  any  local  softening-,  an  incision  should 
be  made  just  in  front  of  the  ear  from  the  zygoma  to  the  angle  of  the 
jaw  down  to  the  capsule  and  the  flap  forcefully  drawn  forward  with 
retractors  (Fig.  394).  If  there  is  edema  of  the  neck  the  incision  may 
extend  to  the  clavicle  through  the  deep  cervical  fascia.  The  trunk 
and  branches  of  the  7th  nerve  lie  deep  in  the  gland,  near  its  posterior 


Fig.    .396.      Shows    packing    in    place. 


Fig.  397.  Sliows  the  extent  of  a 
wound  after  removal  of  the  first  pack- 
ing. 


Fig.     .398.        Shows     the     symmetrical 
action    of    the    facial    muscles. 


Fig.  399.  Shows  the  inconspicuous 
scar  one  year  after  making  the  above 
desci'ibed  exposure  of  the  parotid  gland 
foi-    sepsis. 


part,  and  will  not  be  injured  by  any  carefully  made  incision.  In  this 
way,  nearly  the  whole  gland  can  be  exposed.  By  incisions  carefully 
made  through  the  capsule,  the  swollen  gland  will  be  permitted  to  ex- 
pand, which  will  increase  its  blood  supply  and  lessen  the  danger  of 
gangrene.  If  pus  does  not  come  on  opening  the  capsule,  the  substance 
of  the  gland  can  be  explored  at  various  points  by  inserting  a  round- 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  497 

nosed  artery  forceps,  not  overlooking  the  prolongation  of  the  gland 
that  runs  forward  with  the  first  part  of  the  duct.  If  the  more  radical 
exposure  of  the  capsule  is  made,  the  latter  should  be  incised  in  a  num- 
ber of  places,  thus  liberating  pressure  in  every  part  of  the  gland. 
Failure  to  do  this  in  one  of  the  writer's  cases  made  it  later  necessary 
to  reopen  the  capsule  of  that  part  of  the  gland  that  runs  forward  with 
the  first  part  of  the  duct.  The  operation  requires  but  a  few  minutes 
under  a  gas  anesthesia,  and  the  wound  is  packed  wide  open.  Where  the 
pus  is  not  liberated  by  incision,  it  has  been  reported  to  have  most  fre- 
quently ruptured  into  the  external  auditory  canal,  but  it  may  make  its 
way  into  the  deep  spaces  of  the  neck,  into  the  postpharyngeal  space, 
into  the  mandibular  joint,  or  through  the  olivary  foramen  into  the 
cranial  cavity.  By  thrombosis  of  the  contained  veins,  the  infection  may 
spread  to  the  cranial  cavity,  or  pyemia  may  result.  The  submaxillary 
and  the  sublingual  glands  are  to  be  treated  by  direct  incisions,  or  if 
the  inflammation  is  diffuse,  by  the  writer's  incisions  for  Ludwig's 
angina. 

Parotid  abscess  is  not  of  common  occurrence,  and  it  is  probably  less 
common  now  with  better  routine  sickroom  care  of  the  mouth  than  it 
was  formerly.  The  writer  has  treated  7  cases :  Two  of  mild  grade,  one 
unilateral  in  a  young  child  late  in  the  course  of  pneumonia,  one  bilateral 
in  an  eighteen-year-old  boy,  following  suppurative  appendicitis.  These 
were  treated  by  local  incision  and  drahiage,  and  both  recovered.  There 
was  a  temporary  salivary  fistula  in  both  cases.  Five  of  the  cases  were 
of  a  severe  fulminating  type :  Two  of  the  latter  were  unaccompanied 
by  other  metastatic  foci  and  recovered  after  complete  exposure, — numer- 
ous incisions  in  the  capsule  and  punctures  of  the  gland  itself.  One  of 
these  was  in  a  boy  of  nine  years,  in  whom  the  symptoms  appeared  with- 
out demonstrable  cause;  here  a  streptococcus  was  demonstrated.  The 
other  was  in  a  woman  thirty-five  years  old,  in  whom  the  parotitis  ap- 
peared on  the  fourth  day  of  a  pneumonia,  following  attendance  on  a 
child  who  had  pneumonia.  The  symptoms  were  so  severe  that  she  was 
operated  upon  within  twenty-four  hours  after  the  appearance  of  the 
parotitis,  and  the  incision  was  carried  almost  to  the  clavicle ;  in  this  case 
a  pneumococcus  was  demonstrated.  The  remaining  3  cases  were  in 
women,  one  accompanying  advanced  carcinoma  of  the  stomach,  and  2 
following  operation  for  septic  pelvic  conditions.  In  one  the  general 
sepsis  was  so  severe  that  no  operation  was  done  on  the  parotid ;  in  the 
other  2  the  patients  were  made  more  comfortable,  and  for  a  time  the 
symptoms  ameliorated,  by  a  radical  exposure  and  drainage  of  one  paro- 
tid in  one  and  of  both  parotids  in  the  other;  later  they  both  died  with 
other  metastatic  abscesses  and  general  sepsis.  It  is  such  cases  as  these 
that  lead  one  to  think  that  possibly  the  older  surgeons  were  not  wrong 


498 


SURGERY  OF  THE  ^lOUTH  AND  JAWS. 


in  their  metastatic  conception  of  this  particular  phase  of  parotid  infec- 
tion. In  one  of  the  fatal  cases  there  was  a  partial  paralysis  of  the  7th 
nerve.  In  patients  who  recover,  the  incisions  close  spontaneously  with 
harcllv  a  noticeable  scar. 


Fig.    400.         Congenital    fistula    of   the    parotid    duct    restored    by    construction    of    a 
new    duct   from    the   skin    and   mucous   lining   of   the   cheek. 


CHRONIC  INFLAMMATION. 

Following  any  of  the  chronic  intoxications — such  as  lead,  bismuth, 
opium,  uremia,  etc. — a  subacute  swelling  may  develop  in  both  parotids, 
or  in  any  of  the  salivary  glands,  causing  dififuse  swelling.  They  swell 
slowly  with  occasional  attacks  of  acute  inflammation.  The  ducts  may 
share  in  the  process.     The  tendency  is  toward  spontaneous  recovery. 

Treatment  consists  in  eliminating  the  source  of  poison.  Oral  hy- 
giene should  be  practiced  in  all  cases.  Dry  heat  from  an  electric  light 
should  be  applied,  or  the  counterirritation  of  iodin.  Potassium  iodid, 
internally,  has  been  recommended. 

Inflammatory  Tumor. — This  is  the  name  given  by  Kiittner  to  a 
progressive  chronic  inflammation  of  the  submaxillary  gland,  which 
may  cause  it  to  become  as  large  as  an  orange.  He  has  seen  six  such 
cases  and  describes  them  as  follows : 

"All  cases  involved  the  submaxillary  gland,  though  it  is  probable 
that  the  disease  also  affects  others.  In  marked  cases,  examination 
reveals  a  round  or  elongated  firm  tumor  in  the  submaxillary  region, 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  499 

varying  in  size  from  a  hen's  egg  to  that  of  an  apple.  The  skin  cov- 
ering it  is  inta-ct  or  slightly  adherent ;  upon  the  deep  parts  the  tumor  is 
only  slightly  movable  on  account  of  the  extensive  adhesions,  which 
occasionally  may  involve  the  mucous  membrane  of  the  mouth.  Tender- 
ness may  be  absent  entirely.  The  tumors  are  a  result  of  a  chronic 
interstitial  inflammation  of  a  salivary  gland ;  they  sometimes  contain  in 
their  interior  small  foci  of  granulation  tissue  or  occasional  minute  ab- 
scesses. In  all  the  author's  cases  the  tumors  showed  a  tendency  to 
enlarge  steadily;  they  also  gave  evidence  of  a  decided  tendency  to  im- 
plicate more  and  more  the  surrounding  tissues." 

Diagnosis  is  naturally  difficult.  Kiittner  states  that  they  are  in  no 
way  connected  with  syphilis  and  there  is  nothing  about  them  to  dis- 
tinguish them  from  a  tumor.  Even  at  operation,  the  involvement  of 
the  surrounding  tissues  is  strongly  suggestive  of  a  malignant  growth. 
Such  a  condition  is  but  another  strong  argument  for  the  microscopical 
examination  of  all  undiagnosed  abnormal  masses,  either  before  or  at 
operation. 

Treatment  is  excision  of  the  submaxillary  gland.  In  the  case  of 
the  parotid  gland,  multiple  drainage  might  be  tried. 

PSEUDOHYPERTROPHY  (MIKULICZ'S  DISEASE). 

Under  this  head  has  been  described  a  chronic  symmetrical  enlarge- 
ment of  the  salivary  and  lacrymal  glands.  With  these,  the  palate 
glands,  Blandin's  glands,  the  labial  and  buccal  glands,  the  lymph  nodes, 
and  the  spleen  have  been  observed  to  be  enlarged  in  different  cases. 
The  disease  comes  on  without  other  symptoms  than  the  swelling,  which 
is  strictly  limited  to  the  glands  and  does  not  involve  extracapsular 
structures.  The  glands  of  both  sides  are  not  always  involved  to  the 
same  extent.  The  tumors  are  usually,  but  not  always,  rather  firm. 
According  to  Hirsch,  the  enlargement  is  due  to  an  infiltration  of  round 
cells,  which  is  accompanied  by  an  atrophy  of  the  secreting  epithelium 
and  a  change  of  the  round  cell  infiltration  into  connective  tissue.  He 
therefore  regarded  it  as  a  cirrhosis  of  these  glands.  Besides  the  swell- 
ing, there  are  few  symptoms,  except  those  referable  to  the  decrease 
of  secretion — mostly  dryness  of  the  mucous  membranes.  Nothing 
definite  is  known  of  the  cause,  and  the  course  is  uncertain.  In  some 
cases  the  glands  enlarge  for  a  time  and  then  remain  stationary;  in 
others  they  recede.  Good  results  have  been  reported  from  arsenic 
and  potassium  iodid.  Total  excision  may  be  resorted  to  in  appro- 
priate cases. 

SPECIFIC  INFECTION  OF  THE  SALIVARY  GLANDS. 
Tuberculosis. — Tuberculosis  of  the  salivary  glands  is  a  very  rare 
occurrence  and  is  to  be  distins:uished  from  tuberculosis  of  a  contained 


500  SURGERY  OF  THE  MOUTH  AND  JAWS. 

lymph  node.  There  have  been  a  very  few  cases  reported  of  apparently 
primary  infection  of  the  sahvary  gland,  most  all  occurring  in  otherwise 
healthy  individual.  It  has  always  been  chronic,  appearing  as  a  dififuse 
swelling,  a  node  or  cyst,  with  few  subjective  symptoms.  The  diag- 
nosis from  tumors  is  to  be  made  only  by  the  microscope.  The  treat- 
ment is  excision.  The  whole  submaxillary  gland  should  be  removed, 
but  a  local  operation  may  be  done  on  the  affected  part  of  the  parotid. 
(For  technique,  see  p.  517.)  This  result  of  this  treatment  in  the  re- 
ported cases  has  been  very  good. 

Syphilis. — Syphilis  of  the  salivary  glands  is  also  extremely  rare 
and  has  usually  occurred  in  cases  of  the  more  virulent  type.  It  has 
been  observed  by  Newman  that  in  the  earlier  stages  of  the  disease  the 
gland  presents  a  diffuse  painful  swelling,  but  it  is  usually  a  late  mani- 
festation of  either  a  gummatous  or  interstitial  fibrous  type.  Usually 
there  are  other  marked  signs  of  syphilis,  but  an  immediate  absolute 
diagnosis  from  malignant  tumor,  which  it  may  closely  resemble,  is  only 
to  be  made  by  the  microscope ;  though  a  positive  Wassermann  would 
of  course  be  suggestive,  and  the  disappearance  of  the  swelling  under 
antisyphilitic  treatment  is  almost  conclusive. 

The  treatment  is  the  same  as  for  other  manifestations  of  syphilis. 

Actinomycosis. — This  may  be  part  of  a  neighboring  infection, 
or  it  may  have  gained  entrance  to  the  gland  through  the  duct.  The 
diagnosis  in  the  later  stages,  after  sinuses  have  formed,  is  to  be  made 
by  the  finding  of  the  fungus. 

The  treatment  is  the  same  as  that  for  the  same  infections  at  other 
sites. 

OBSTRUCTION  OF  THE  DUCTS  OF  THE  SALIVARY 
GLANDS.     CYSTS. 

The  ducts  may  be  partially  obstructed  from  calculi,  swelling  or 
neighboring  cysts,  swellings,  or  tumors.  Plugs  of  mucus,  foreign 
bodies,  or  even  small  calculi  plugging  the  exit  of  a  salivary  duct  will 
cause  an  accumulation  of  fluid  which,  if  it  persists,  may  cause  a  dilata- 
tion of  all  of  the  ducts  emptying  into  the  obstructed  one,  converting  all 
into  an  epithelial-lined  cavity.  In  the  sublingual  glands,  the  terminal 
ducts  of  which  are  small  and  numerous,  the  plugging  of  one  of  them 
is  more  liable  to  be  permanent,  which  constitutes  one  of  the  forms  of 
ranula.  In  the  submaxillary  and  parotid  glands,  each  of  which  empty 
their  secretions  through  a  long  duct  of  comparatively  large  caliber, 
permanent  obstruction  rarely  occurs. 

The  symptoms  of  an  acute  obstruction  of  one  of  the  larger  ducts 
are :  great  pain,  made  worse  by  eating  or  the  sight  of  food ;  and  a  fusi- 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  501 

form  swelling  corresponding  to  the  duct,  with  swelling  of  the  whole 
gland.  If  the  obstruction  is  not  relieved  naturally,  or  by  passing  a 
sound  or  by  slitting  the  duct,  suppuration  may  follow.  In  partial  ob- 
struction there  are  pain  and  swelling  of  both  the  duct  and  gland  when- 
ever the  secretion  is  stimulated,  but  this  subsides  as  the  accumulation 
of  saliva  gradually  forces  its  way  out.  Partial  obstruction  of  the  larger 
ducts  is  much  more  common  than  complete  obstruction,  and  when 
caused  by  the  inflammation  around  a  stone  or  other  foreign  body,  is 
likely  to  be  recurrent.  In  the  few  cases  that  have  been  reported  of 
permanent  distension  of  the  parotid  or  submaxillary  duct,  the  obstruc- 
tion has  in  most  instances  been  due  to  a  scar  stricture  or  a  foreign  body. 
In  a  few  the  obstruction  was  congenital,  and  in  others  there  was  a 
cystic  distention  of  the  duct  without  any  demonstrable  obstruction.  In 
the  latter  cases  the  secretion  could  be  expressed  out  of  the  duct,  but 
would  reaccumulate.  According  to  laboratory  experiments,  absolute 
occlusion  of  the  main  excretory  duct  causes  atrophy  of  the  gland.  This 
does  not  agree  with  the  accepted  idea  that  most  ranulae  are  due  to  sub- 
lingual duct  obstruction. 

Diagnosis.  — The  diagnosis  is  easily  made  from  the  location  of 
the  swelling  and  the  increase  of  symptoms,  which  occurs  during  eating 
or  even  at  the  sight  of  food,  due  to  the  increased  flow  of  saliva.  If 
convenient,  an  x-ray  picture  should  be  taken  to  locate  a  possible  stone, 
but  if  this  is  not  convenient  and  a  stone  or  foreign  body  is  suspected, 
search  is  to  be  made  with  a  needle.    (See  p.  503.) 

Treatment. — An  attempt  should  be  made  to  pass  a  fine  probe 
into  the  duct,  which  may  dislodge  or  locate  the  obstruction.  As  large 
a  probe  as  will  easily  enter  the  duct  should  be  selected,  but  no  force 
should  be  used,  as  a  false  passage  might  be  formed.  It  may  be  pos- 
sible to  massage  a  foreign  body  out  of  the  mouth  of  a  duct.  If  the 
obstruction  can  be  located  and  is  not  completely  relieved  by  the  passage 
of  the  probe,  it  should  be  cut  down  upon  and  removed  as  early  as 
possible.  A  stone,  responsible  for  the  inflammation  or  scar  contraction 
which  is  causing  the  obstruction,  may  have  dropped  back  and  may  be 
found  lying  free  in  the  cavity  when  the  cyst  is  opened.  If  no  definite 
cause  for  the  obstruction  is  found  and  it  cannot  be  relieved  by  simply 
passing  a  probe  and  frequently  emptying  the  duct,  then  the  cystic  dilata- 
tion of  the  duct  should  be  freely  incised.  Then,  if  no  foreign  body  is 
present,  further  treatment  may  not  be  needed,  for  the  frequent  dis- 
charge of  saliva  from  a  large  duct  will  probably  maintain  a  permanent 
fistula.  Should  this  treatment  fail,  a  piece  of  the  outer  wall  of  the 
cyst  can  be  removed  with  its  mucous  covering.  Another  plan  is  to  use 
a  silk  or  twisted  silver-wire  seton. 


503  SURGERY  OF  THE  MOUTH  AND  JAWS. 

FOREIGN   BODIES   AND   STONES   IN   THE   DUCTS   AND 

GLANDS. 

Improbable  as  it  may  seem,  foreign  bodies — such  as  pieces  of  grain, 
apple  seeds,  bits  of  tartar,  etc. — have  occasionally  found  their  way  into 
the  submaxillary  duct,  causing  acute  obstruction.  In  other  instances 
the  obstruction  has  not  been  complete,  and  no  obstructive  symptoms 
were  noticed  until  inflammation  occurred  around  the  intruder.  Only 
slender  bodies,  such  as  fish  bones  or  bristles,  can  enter  the  opening  of 
the  parotid  duct,  on  account  of  its  smaller  size.  With  the  exception 
of  calculi,  which  are  formed  in  place,  foreign  bodies  reach  the  glands 
only  from  without.  If  a  body  in  the  duct  is  not  removed,  suppuration 
usually  sooner  or  later  supervenes  with  symptoms  of  partial  or  com- 
plete obstruction.  Foreign  bodies  which  have  entered  a  gland  and 
healed  in  place  are  less  likely  to  cause  symptoms.  A  bullet  may  heal 
in  place.  A  foreign  body  in  the  duct  will  in  time  become  coated  with 
lime  salts,  when  it  is  to  all  purposes  a  salivary  calculus. 

The  diagnosis  of  a  foreign  body,  unless  it  can  be  seen  or  the  history 
of  its  entrance  is  clear,  is  only  tentative  until  it  can  be  exposed  or  felt. 
(For  methods  of  examining  for  foreign  bodies,  see  Examination  for 
Stones,  page  503.)  A  soft  body  will  not  cast  a  shadow  upon  the  x-ray 
plate  and  can  with  difficulty  be  felt  with  an  exploring  needle.  On  the 
other  hand,  they  are  usually  situated  near  the  orifice  of  the  duct,  where 
they  can  be  felt  with  a  probe.  The  treatment  is  the  same  as  for 
stones. 

Salivary  Calculi. — Salivary  calculi  can  form  in  the  glands  them- 
selves, or  in  their  excretory  ducts,  the  latter  being  the  more  common 
situation.  Calculi  in  Blandin's  glands,  though  not  salivary  glands,  are 
included  under  this  heading.  Calculi  form  in  the  salivary  glands  and 
ducts  less  frequently  than  in  the  kidneys  or  liver.  Though  some  of 
them  may  have  as  their  matrix  some  foreign  body  which  has  entered 
the  duct,  it  is  probable  that,  like  stones  in  other  situations,  they  most 
frequently  owe  their  origin  to  the  presence  of  bacteria;  these,  to- 
gether with  a  change  in  the  mucous  secretion,  which  they  cause,  fur- 
nish the  matrix  of  the  stone.  A  matrix  of  a  stone  having  once  formed, 
the  same  conditions  of  metabolism  which  influence  the  rapidity  of 
the  deposit  of  tartar  on  the  teeth  must  also  influence  the  rate  of  stone 
formation  in  the  ducts. 

The  most  common  location  of  salivary  calculi  is  in  the  submaxillary 
duct,  being  more  frequent  here  than  in  all  other  locations  combined. 
They  are  more  common  in  men,  and  rarely  occur  in  children,  but  have 
been  congenital.  Usually  there  is  but  one  stone,  the  size  of  a  pea  or 
smaller,  but  they  may  be  of  large  size — one  reported  by  Pusey  having 
reached  the  dimensions  of  >^  by  1  by  1^  inches  and  weighing  7.6 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  50:; 

grams.  There  may  be  more  than  one  stone,  the  size  of  the  stones  being 
smaller  when  there  are  a  number  of  them.  When  the  stones  form  in  the 
secondary  ducts  of  a  gland,  there  may  be  a  great  number  of  them,  which 
are  apt  to  be  thrown  into  the  common  duct,  there  to  collect  or  to  be 
thrown  off  through  the  normal  opening. 

A  stone  in  a  duct  may  cause  no  symptoms  for  a  long  time  and  will 
not  do  so  until  there  is  partial  obstruction,  or  until  a  pus  infection 
occurs.  The  symptoms  of  partial  obstruction  of  a  duct  are  given  on 
page  500.  Infection  around  a  stone  is  accompanied  by  swelling,  usually 
pain,  and  possibly  suppuration  or  a  diffuse  cellulitis.  As  the  result  of 
one  or  repeated  inflammations,  the  stone  may  come  to  lie  in  a  bed  of 
scar  tissue,  in  an  abscess,  in  the  bottom  of  a  fistula,  or  in  a  mass  of 
fungating  granulations  and  indurated  tissue.  The  last  condition  has 
several  times  been  mistaken  for  a  malignant  growth,  and  extensive, 
mutilating  operations  have  been  performed.  When  the  stone  lies  in 
an  indurated  mass,  which  has  attached  itself  to  the  bone,  it  may  be 
mistaken  for  a  periosteitis,  and  the  real  cause  overlooked.  If  un- 
treated, a  stone  may  lie  in  its  bed  indefinitely,  with  or  without  marked 
symptoms,  or  may  eventually  ulcerate  its  way  through  into  the  mouth. 
less  rarely  to  tne  external  surface. 

The  diagnosis  is  to  be  made  partly  upon  the  symptoms  referable 
to  the  obstruction  of  the  duct  (see  page  500)  and  the  inflammation  of 
the  tissues,  and  partly  by  special  examinations.  The  stone  is  rather 
impervious  to  the  x-ray,  and  a  good  negative  is  probably  the  best  way 
of  locating  or  excluding  small  stones.  For  the  positive  diagnosis  of 
small  stones  in  the  submaxillary  or  parotid  gland,  the  x-ray  may  be 
absolutely  necessary.  A  probe  of  soft  silver  passed  into  the  duct  may 
locate  a  stone,  and  while  there  is  no  mistaking  the  definite  grating  sen- 
sation which  usually  results  from  the  probe  sliding  over  the  stone, 
the  lack  of  this  does  not  exclude  stone;  for  the  probe  may  not  have 
passed  as  far  as  the  stone,  or  the  stone  may  be  in  a  pocket.  To  us  the 
most  practical  examination  is  by  means  of  a  strong  hypodermic,  used 
as  an  exploring  needle.     The  examination  is  conducted  as  follows : 

The  most  marked  part  of  the  induration,  or  its  most  tender  point, 
is  located  by  a  bimanual  examination.  The  surface  over  this  is  painted 
with  a  10  per  cent  cocain  solution.  A  hypodermic  syringe  with  a  strong 
needle  is  filled  with  a  solution  containing  ^  per  cent  novocain  and 
1  per  cent  of  the  1 :1000  adrenalin  chlorid  solution.  The  needle  is 
plunged  into  the  suspected  tissue,  infiltrating  as  it  progresses,  which, 
if  done  slowly,  lessens  the  pain.  Careful  search,  by  repeated  insertions 
of  the  needle,  is  made  all  along  the  suspected  area,  and  when  the  stone 
is  found,  a  fair  idea  of  its  size,  or  the  size  of  a  mass  of  stones,  can  be 
obtained  in  this  way.     By  the  time  the  examination  is  completed,  the 


504  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tissues  are  well  anesthetized,  and  if  it  is  a  suitable  case  for  removal 
under  a  local  anesthetic,  the  operation  can  proceed  without  further 
preparation. 

Treatment. — All  stones  and  foreign  bodies  should  be  removed. 
For  stones  situated  in  the  submaxillary  duct  or  anywhere  under  the 
mucous  membrane,  this  is  usually  not  difficult.  For  a  number  of  stones 
in  the  submaxillary  gland,  the  latter  may  be  excised ;  but  a  stone  situ- 
ated in  the  parotid  gland,  a  rare  occurrence,  would  present  some  serious 
considerations.  A  stone  situated  in  Blandin's  duct,  in  the  parotid  duct, 
in  the  sublingual  gland,  or  in  the  submaxillary  duct  in  front  of  the 
molar  teeth  can  be  removed  with  a  local  anesthetic ;  but  a  submaxillary 
stone  situated  behind  the  bicuspids,  or  in  any  situation  in  a  nervous 
patient,  had  better  be  removed  under  a  general  anesthetic.  A  sub- 
maxillary duct  stone  having  been  located,  it  is  pushed  upward  into  the 
mouth  by  the  fingers  of  an  assistant  placed  under  the  jaw.  A  gag  is 
placed  in  the  mouth,  and  the  cheek  is  retracted.  With  the  forefinger 
of  the  left  hand  the  operator  attempts  to  steady  the  stone  against  the 
body  of  the  jaw.  An  incision  of  some  length  is  made  down  to  the 
stone,  and  unless  there  is  very  profuse  bleeding,  no  attempt  is  made  to 
control  it,  since  the  work  has  to  be  done  entirely  by  touch. 

If  the  knife  fails  to  touch  the  stone,  it  must  be  relocated  with  a 
needle.  The  freeing  of  a  single  stone  is  often  not  an  easy  matter. 
These  stones  frequently  present  uneven  surfaces,  and  it  is  difficult  to 
cut  through  strands  of  tissue  which  have  gripped  the  stone  in  the 
little  space  between  the  nodules.  For  this  purpose  a  small  pointed 
tenetome  is  useful,  cutting  repeatedly  with  the  point  of  the  knife  along 
the  same  line  on  the  surface  of  the  stone  and  at  the  same  time  attempt- 
ing to  work  the  tissues  from  the  stone  by  lateral  strokes  of  the  point 
of  the  knife.  If  possible,  the  stone  should  be  freed  in  this  way  until 
an  elevator  or  small  curette  can  be  slipped  under  it.  It  is  not  good 
practice  to  undertake  to  grasp  the  stone  with  forceps  thrust  into  the 
depth  of  the  wound;  for  one  is  more  liable  than  not  to  include  some 
soft  tissue  in  the  bite,  and  it  would  be  possible  to  do  damage.  The 
lingual  nerve  crosses  beneath  the  duct  from  the  external  to  the  median 
side  at  the  first  or  second  molar  tooth,  but  if  one  cuts  straight  down 
on  the  stone  and  does  not  make  grabs  in  the  depth  of  the  wound,  it  is 
in  little  danger  of  injury. 

After  removal  of  the  stone,  search  should  be  made  for  pos- 
sible neighbors.  A  nest  of  small  stones  is  easier  to  remove  than  one 
large  one.  They  can  be  scooped  out  of  a  comparatively  small  hole  with 
a  curette.  The  wound  is  packed  lightly  for  a  day  or  two,  after  which, 
if  all  the  stones  have  been  removed,  no  further  treatment  than  a 
mouth  wash  is  needed. 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  505 

A  stone  in  the  oral  part  of  the  parotid  duct  is  treated  in  the  same 
way.  For  a  stone  farther  back  in  this  duct,  it  seems  to  us  that  the  best 
procedure  would  be  to  go  down  to  it  with  a  clean  cut,  remove  the 
stone,  and  after  passing  a  probe  into  the  mouth  to  be  sure  that  the  duct 
is  patent,  suture  the  facial  wound  in  its  full  depth.  The  danger  here 
is  that  a  salivary  fistula  might  result, 

A  single  stone,  or  several  of  them,  could  be  removed  from  the 
parotid  in  the  same  manner  as  are  tumor  nodules  (see  page  517),  but 
if  it  were  ever  deemed  necessary  to  remove  the  whole  gland,  it  should 
be  done  piecemeal,  after  locating  the  trunk  of  the  facial  nerve  and  free- 
ing its  branches. 

WOUNDS  OF  THE  SALIVARY  GLANDS  AND  DUCTS. 

Wounds  of  the  glands  may  be  followed  by  an  external  flow  of  saliva, 
but  this  usually  ceases  spontaneously  in  some  weeks. 

Recent  clean  injuries  should  be  sutured  to  their  full  depth  and 
drained  so  that  the  deeper  part  of  the  wound  cannot  be  distended.  In- 
fected wounds  may  have  to  be  dressed  open  until  clean  enough  to  be 
sutured,  and  when  this  is  done,  intraoral  drainage  should  be  provided, 
if  an  external  flow  of  saliva  has  persisted. 

Lateral  injuries  of  a  duct  will  eventually  heal  without  fistula  unless 
there  is  considerable  loss  of  substance.  If  the  duct  is  cut  completely 
through,  the  ends  will  retract,  and  the  cut  end  of  the  distal  part  will 
eventually  close.  In  recent  injuries  of  the  duct,  an  attempt  may  be 
made  to  suture  the  duct  with  fine  catgut  which  does  not  penetrate  the 
mucous  lining.  This  is  a  difficult  procedure.  In  suturing  the  duct, 
the  proper  approximation  of  the  ends  is  more  of  an  object  than  to 
make  a  water-tight  joint.  Whether  or  not  the  duct  is  sutured,  free 
drainage,  preferably  into  the  mouth,  should  be  made,  and  the  tissues 
superficial  to  the  duct  should  be  accurately  sutured.  (See  Treatment 
of  Salivary  Fistula,  p.  507.) 

SALIVARY  FISTULA. 

A  salivary  fistula  is  an  abnormal  communication  between  a  surface 
and  a  salivary  duct  or  gland,  through  which  saliva  is  discharged. 
These  fistulae  may  be  external  or  internal,  but  ordinarily  internal  fistulae 
are  of  no  surgical  interest,  further  than  that  their  patency  is  necessary 
if  there  is  an  occlusion  of  the  distal  part  of  the  duct.  Rarely  an  ex- 
ternal fistula  of  the  submaxillary  gland,  or  even  of  the  duct,  may  result 
from  a  deep  external  wound,  or  an  ulceration  or  abscess  due  to  a  stone, 
but  practically  all  external  salivary  fistulae  are  of  the  parotid  gland  or 
its  duct.  Gland  fistulae  which  commonly  result  from  operations  on 
theglandorfromtheruptureof  abscesses  are  of  less  importance,  both 


506  SURGERY  OF  THE  MOUTH  AND  JAWS. 

because  they  usually  heal  spontaneously  and  because  the  resulting 
symptoms  are  not  as  severe  as  those  of  duct  fistulae.  Duct  fistulae  most 
commonly  come  as  a  result  of  ill-placed  incisions  or  from  accidental 
wounds,  but  they  may  result  from  any  ulcerative  process — such  as 
noma,  gumma,  or  carcinoma.  In  gland  fistula  only  a  part  of  the 
secretion  is  lost,  but  in  duct  fistula  the  whole  amount  is  apt  to  pour 
out  on  the  cheek.  Some  general  depression  may  result  from  the  dis- 
iaclination  which  the  patient  has  toward  eating,  but  the  chief  evil  is 
the  annoyance  and  embarrassment  due  to  the  presence  of  the  abnormal 
flow.  Between  meals  this  flow  is  small ;  while  taking  food  the  quantity 
is  considerable.  Duphenix  collected  70  grams  from  a  patient  in  fifteen 
minutes,  and  Jobert  had  a  patient  who  voided  several  cupfuls  in  twenty- 
four  hours.  Usually  the  mouth  of  the  fistula  presents  a  few  granu- 
lations which  may  be  surrounded  by  scar  or  normal  skin,  but  in  the 
duct  fistula  there  may  be  a  smooth  union  between  the  mucous  lining 
and  the  skin.  A  recent  fistula  to  a  duct,  which  is  still  patent  at  its 
distal  end,  is  likely  to  heal  spontaneously  or  with  a  little  help,  such  as 
local  cauterization  and  pressure;  but  a  fistula  to  a  duct  which  is  oc- 
cluded or  very  much  contracted,  or  a  fistula  in  which  the  mucous  lining 
of  the  duct  has  united  directly  to  the  skin,  will  close  only  after  some 
successful  radical  operation.  In  reference  to  their  repair,  the  loca- 
tion of  the  fistula  and  the  amount  of  destruction  in  the  distal  part  of 
the  duct  are  of  most  importance — those  situated  in  the  buccal  part  of 
the  duct  being  easily  corrected,  and  those  situated  farther  back  having 
been  considered  more  difficult  of  repair. 

Diagnosis. — Except  in  the  early  stages  "of  a  fistula  following  an 
abscess,  or  of  one  occurring  in  a  suppurating  wound,  where  the  saliva 
might  be  disguised  by  the  pus,  the  diagnosis  of  the  salivary  fistula  is 
very  simple.  The  discharge  is  perfectly  clear,  is  increased  during 
eating,  and  usually  there  is  some  irritation  of  the  skin  which  is  con- 
tinuously wet  with  the  discharge.  In  a  case  observed  by  Angieras, 
cited  by  Kuttner,  in  which  an  internal  fistula  had  opened  into  the  max- 
illary antrum,  there  was  a  profuse  discharge  from  the  nose.  Such  a 
case  would  be  quite  perplexing  until  the  recurrence  of  the  discharge 
while  eating  might  lead  to  an  analysis  of  the  fluid. 

While  a  salivary  fistula  is  usually  recognizable  at  a  glance  or  after 
a  few  questions,  there  are  certain  points  which  should  be  carefully  de- 
termined. These  are :  the  cause  of  the  fistula ;  the  exact  site  of  the 
defect,  whether  of  duct  or  gland;  the  extent  of  the  injury  to  the  duct; 
the  distance  between  the  skin  opening  and  the  duct  injury;  and  the 
condition  of  the  duct  distal  to  the  fistula.  All  of  these  bear  upon  the 
prognosis  and  treatment  and  can  only  be  determined  after  certain 
examinations. 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  507 

Simple  fistulae  leading  to  mucons-lined  cavities  or  ducts  in  any 
part  of  the  body  have  a  distinct  tendency  to  heal  spontaneously,  and 
unless  the  wall  of  the  fistula  is  diseased,  as  with  a  tuberculous  infection, 
unless  the  fluids  within  the  duct  or  cavity  can  find  an  easy  exit  only 
through  the  fistula,  or  unless  the  mucous  lining  of  the  duct  is  united 
directly  to  the  skin,  the  fistula  will  always  close  of  itself.  This  is  true 
of  salivary  fistulae,  and  the  condition  in  relation  to  these  points  should 
be  determined  before  treatment  is  begun.  Specific  ulcerations  will  need 
to  be  cured  before  any  attempt  can  be  made  to  close  the  fistula.  A  gland 
fistula  can  usually  be  recognized  by  its  location,  or,  if  it  opens  some 
distance  from  the  gland,  by  its  direction  and  the  fact  that  only  a  small 
part  of  the  whole  secretion  is  discharged  through  it.  The  attachment 
of  the  mucous  lining  of  the  duct  directly  to  the  skin  may  sometimes 
be  made  out  by  inspection,  or  can  be  inferred  if  the  fistula  has  no  depth. 
The  condition  of  the  distal  part  of  the  duct  and  orifice  can  usually  be 
determined  by  attempting  to  pass  probes  both  from  the  fistula  and 
through  the  orifice  and  by  injecting  methylene-blue  solution  into  the 
fistula. 

Treatment. — Many  fistulae  of  recent  origin  will  close  spontaneously 
if  absolute  rest  be  given  by  intermaxillary  fixation,  and  the  patient  put 
upon  a  milk  diet.  Most  duct  fistulae  which  have  persisted  for  six 
months  will  demand  some  sort  of  radical  treatment,  but  a  gland  fistula 
is  usually  cured  by  simpler  methods.  Usually  repeated  applications  of 
silver  nitrate  or  the  electric  cautery  into  the  depth  of  a  gland  fistula 
and  the  application  of  pressure  will  bring  about  a  cure. 

Animal  experimentation  has  shown  that  the  tying  of  the  excretory 
duct  of  a  gland  brings  about  an  atrophy  of  its  secreting  cells,  and  it  is 
possible  that  the  inflammation  and  scarring,  which  result  from  the 
cautery,  block  the  small  ducts  that  lead  into  the  fistula.  If  repeated 
applications  of  the  cautery,  followed  by  pressure  and  restriction  of  diet 
to  non-appetizing,  unspiced  fluids,  fails  to  produce  a  cure,  then  the 
offending  part  of  the  gland  must  be  excised,  having  first  located  and 
freed  the  branches  of  the  facial  nerve. 

Duct  fistulae  are  treated  in  several  different  ways,  the  choice  de- 
pending upon  both  the  location  of  the  defect  and  the  condition  of  the 
distal  part  of  the  duct.  Very  recent  fistulae  may  be  treated  by  cauter- 
ization of  the  outlet,  and  pressure  or  the  application  of  impervious 
adhesive  plaster.  In  cases  where  a  permanent  fistula  is  situated  in  the 
buccal  part  of  the  duct  or  near  the  anterior  border  of  the  masseter 
muscle,  the  external  fistula  may  be  converted  into  an  internal  one,  or 
the  proximal  part  of  the  duct  may  be  implanted  directly  into  the  buccal 
mucous  membrane.  When  the  fistula  is  situated  too  far  back,  the  duct 
can  sometimes  be  repaired  by  suture,  or  by  piecing  out  with  a  prolon- 


508  SURGERY  OF  THE  MOUTH  AND  JAWS. 

gation  made  from  the  buccal  mucous  membrane.  After  removing  a 
section  of  the  masseter  muscle,  and  if  necessary,  part  of  the  anterior 
border  of  the  ramus,  the  end  of  the  duct  can  be  planted  directly  into 
the  mucosa  of  the  mouth. 

Conversion  of  an  External  into  an  Internal  Fistula. — There  are 
two  general  plans  for  doing  this :  (1)  the  establishment  of  a  new  fistula 
by  means  of  a  seton ;  (2)  passing  a  small  drainage  tube  through  the 
cheek  at  the  site  of  the  duct  defect  and,  gradually  withdrawing  it  from 
the  inner  side,  allowing  the  external  fistula  to  heal,  while  the  internal 
one  remains  patent.  The  latter  is  Kaufmann's  method  and  is  carried 
out  as  follows : 

A  trocar,  4  or  5  millimeters  in  diameter,  is  pushed  through  the 
cheek  at  the  site  of  the  fistula.  It  is  very  important,  for  success,  that 
the  trocar  penetrate  exactly  at  the  site  of  the  hole  in  the  duct  and  that 
the  deeper  part  of  the  external  fistula  is  not  separated  from  the  new 
tract  by  a  thin  wall  of  tissue,  which  may  effectually  prevent  the  saliva 
finding  its  way  into  the  mouth.  A  small  spirally  cut  drainage  tube  is 
placed  through  the  cannula,  and  the  latter  is  withdrawn,  leaving  the 
tube  in  place.  The  tube  may  be  treated  in  several  different  ways,  one 
of  which  is  to  withdraw  it  toward  the  mouth  until  the  external  end 
disappears  beneath  the  skin.  The  internal  end  is  cut  about  3  milli- 
meters beyond  the  mucous  surface,  and  then  the  patient  is  allowed  to 
chew  some  food  while  the  finger  is  pressed  gently  over  the  external 
opening.  If  the  tube  is  properly  placed,  saliva  should  flow  into  the 
mouth.  When  it  is  determined  that  the  saliva  can  reach  the  mouth, 
the  end  of  the  tube  is  made  steady  by  grasping  it  and  the  mucous 
membrane  gently  with  an  artery  forceps,  and  a  retention  suture  is 
passed  through  both  and  tied.  The  external  opening  is  carefully  dried 
and  covered  with  a  piece  of  adhesive  plaster.  As  the  stay  suture  cuts 
its  way  out,  the  drainage  tube  will  be  gradually  forced  out;  but  it 
should  remain  in  place  for  two  weeks,  and  if  the  external  fistula  is  still 
open,  it  should  be  replaced  if  it  comes  out  before  that  time.  If,  after 
a  few  days,  the  external  orifice  has  not  closed,  it  may  be  cauterized  or 
freshened  and  sutured.  If  there  is  a  depression  at  the  site  of  the  ex- 
ternal opening  surrounded  by  a  scar,  it  will  save  time  and  give  a  better 
cosmetic  result  to  at  once  excise  this,  undermine  the  skin,  and  draw  it 
together  by  immediate  suture.  This  operation  can  be  done  under  a 
local  anesthetic  without  detaining  the  patient  from  his  business.  There- 
fore, if  the  first  attempt  is  not  entirely  successful,  it  should  be  imme- 
diately repeated. 

Another  way  of  establishing  an  internal  fistula  is  to  thread  a  strip 
of  live  rubber  dam,  3  millimeters  wide  and  20  centimeters  long,  on  a 
straight  needle  which  is  inserted  to  the  bottom  of  the  fistula  and  on 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  509 

through  the  cheek.  This  end  being  allowed  to  remain  protruding  into 
the  mouth,  the  other  end  is  threaded  upon  the  needle,  which  is  also  in- 
serted through  the  cheek  from  the  bottom  of  the  external  fistula,  but  in 
such  a  manner  that  there  will  be  about  1-centimeter  space  between  the 
two  points  at  which  the  dam  pierces  the  buccal  mucous  membrane. 
The  two  ends  of  the  dam  strip  are  tied  together  with  just  a  little  tension, 
which  will  eventually  cut  through  the  intervening  tissue.  The  dam 
should  not  be  drawn  tight  as  it  is  tied,  for  it  would  then  cut  through  in  a 
day  or  two  and  not  stay  in  place  long  enough.  If,  after  the  fistula  is 
well  established,  the  seton  does  not  cut  its  way  out,  it  can  be  tightened 
by  tying  a  ligature  around  the  two  internal  ends  between  the  knot  and 
the  mucous  membrane. 

The  external  opening  is  treated  as  in  Kaufmann's  operation. 

Repair  of  the  Duct. — Most  of  the  work  on  repair  of  the  duct  has 
been  done  by  Nicoladoni.  If  a  fair-sized  probe  can  be  passed  from  the 
mouth  to  beyond  the  fistula,  this  may  be  taken  as  evidence  that  there 
is  only  a  lateral  wound  in  the  duct  which  is  being  kept  patent  by  the 
continuity  of  the  skin  and  mucosa.  The  duct  should  be  exposed  by 
an  elliptical  incision  around  the  fistula,  joined  by  straight  incisions  over 
the  neighboring  parts  of  the  duct. 

In  exposing  the  duct,  the  surrounding  tissue  should  not  be  stripped 
oflf  too  closely,  for  this  might  interfere  with  its  blood  supply.  Having 
exposed  the  duct  sufficiently,  an  attempt  should  be  made  to  repair  the 
defect  with  part  of  the  epithelial  tissue  surrounding  the  fistula,  retain- 
ing only  a  sufficient  amount  for  the  purpose,  and  this  must  contain  no 
hair.  The  epithelial  surface  should  be  turned  toward  the  lumen  so  as 
to  form  part  of  the  lining  of  the  duct.  The  sutures  should  be  of  the 
finest  tannated  gut  and  so  placed  that  they  will  not  be  exposed  on  the 
epithelial  surface  of  the  lumen.  If  any  part  of  a  suture  were  left 
within  the  duct,  that  part  would  not  be  absorbed  and  might  subsequently 
form  the  matrix  of  a  stone.  This  suturing  is  to  be  done,  not  so 
much  with  the  idea  of  making  a  water-tight  joint,  as  simply  assur- 
ing the  proper  relation  of  the  flaps  until  healing  occurs.  After  closing 
the  defect,  an  effort  should  be  made  to  bury  the  newly  repaired  duct 
deeply. 

Nicoladoni  does  a  plastic  operation  upon  the  skin,  by  which  the 
newly  repaired  part  of  the  duct  is  covered  by  a  fiap  and  not  by  the 
skin  wound,  so  that  there  will  be  no  possibility  of  the  epithelial  edges 
of  the  defect  becoming  united  to  the  skin.  In  cases  in  which  a  lateral 
repair  of  the  duct  cannot  be  made,  Nicoladoni  has  done  an  end-to-end 
anastomosis  of  the  duct  with  a  very  fine  catgut.  The  suturing  would 
be  facilitated  if  the  two  ends  of  the  duct  were  cut  cleanly  across  and 
a  sound  passed  from  the  mouth  were  introduced  into  the  lumen  of  both 


510  SURGERY  OF  THE  MOUTH  AND  JAWS. 

ends  of  the  duct.  A  fistula  following  these  operations  does  not  neces- 
sarily mean  failure.  If  the  epithelial  lining  has  been  properly  placed 
and  the  caliber  of  the  duct  has  been  restored  at  the  time  of  the  oper- 
ation, then,  even  though  subsequent  swelling  may  for  a  time  block  the 
duct  and  force  the  saliva  out  through  the  wound,  later  when  swelling 
subsides,  the  fistula  will  close,  and  the  saliva  will  follow  the  normal 
route.  Where  the  duct  is  found  too  short  for  an  end-to-end  anasto- 
mosis, Nicoladoni  has  resorted  to  the  following  expedient  for  approxi- 
mating the  two  cut  ends : 

He  exposes  the  distal  portion  of  the  duct  for  its  full  length,  but 
leaves  around  it  sufficient  tissue  to  insure  its  blood  supply.  The  outer 
surface  of  the  buccinator  muscle  is  exposed  for  some  distance  around 
the  entrance  of  the  duct.  The  natural  opening  of  the  duct  is  sur- 
rounded by  a  horseshoe-shaped  incision,  which  liberates  a  fair-sized 
flap  of  buccinator  and  mucous  membrane,  that  has  its  base  posteriorly. 
This  flap  carries  its  blood  supply.  By  this  means  the  distal  part  of  the 
duct  can  be  drawn  backward  1  centimeter  or  more. 

Reconstruction  of  the  Distal  Part  of  the  Duct  from  the  Buccal 
Mucosa. — The  idea  of  piecing  out  the  duct  with  buccal  mucous 
membrane  was  first  presented  by  Nicoladoni  and  Braun.  If  the  buccal 
mucosa  is  unscarred,  it  is  very  movable  and  can  be  used  as  follows : 

The  mucous  membrane  of  the  cheek  with  its  submucous  tissue  is 
laid  bare  for  some  distance  through  a  transverse  incision  in  the  ex- 
ternal surface  of  the  cheek.  Two  parallel  transverse  cuts  are  made  in 
the  buccal  mucosa,  IJ/2  centimeters  apart.  The  central  part  of  the  flap 
thus  outlined  can  be  drawn  for  some  distance  back  on  the  outer  surface 
of  the  masseter.  If  the  proximal  end  of  the  duct  is  long  enough  to  be 
implanted  into  the  end  of  this  double  fold,  this  is  done,  and  the  fold  is 
held  in  its  new  position  by  two  sutures,  placed  one  at  each  corner.  By 
a  running  suture  of  catgut  at  the  upper  and  lower  borders,  this  double 
fold  of  mucus  is  converted  into  a  tube.  The  new  duct  is  buried  as 
deeply  as  possible.  If  the  duct  is  too  short  to  be  pieced  out  in  this 
way,  a  tongue  of  mucous  membrane  with  its  base  posterior  is  turned 
back  and  converted  into  a  tube,  into  which  the  proximal  end  of  the 
duct  is  sutured. 

Transplantation  of  the  End  of  the  Proximal  Portion  of  the  Duct 
into  the  Buccal  Mucosa. — This  is  von  Langenbeck's  operation,  but 
he  confined  it  to  cases  in  which  the  proximal  part  of  the  duct  was  suffi- 
ciently long  to  allow  of  the  end  being  inserted  into  the  mucous 
membrane  in  front  of  the  masseter  muscle.  It  is  just  these  cases 
which  are  fitted  for  the  much  simpler  procedure  of  establishing  an 
internal  fistula.  Nicoladoni  went  farther  and  excised  the  anterior 
border  of  the  muscle  to  allow  of  a  short  duct  being  implanted  more 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  511 

posteriorly.  Partly  on  theoretical  grounds,  partly  on  experimental 
operations  upon*  the  cadaver  and  from  observation  of  other  operations 
on  this  region  which  involved  the  destruction  of  the  masseter  muscle 
and  ramus,  we  concluded  that  von  Langenbeck's  operation  might  be 
applied  to  any  duct  fistula  situated  between  the  anterior  border  of  the 
masseter  and  the  gland,  if  the  intervening  muscle  and  bone  were  re- 
moved. This  operation  is  more  likely  to  be  followed  by  success  than 
either  of  those  which  have  been  described  for  fistula  in  this  situation. 
The  direct  suturing  of  the  duct  or  the  repair  of  a  lateral  defect  is  very 
nice  surgery,  but  is  more  appropriate  for  the  expert  who  has  made  a 
special  study  of  the  technic  than  for  one  who  has  not.  Even  in  the 
expert's  hands,  it  seems  to  us  that  there  are  many  opportunities  for 
failure,  as  also  in  the  grosser  operation  of  Nicoladoni  and  Braun.  An 
infection  might  cause  the  retention  sutures  to  cut  through  before  the 
new  tube  had  been  fixed  in  its  position,  and  in  this  way  failure  could 
result.^ 

The  destruction  of  one  masseter  muscle  and  one  ramus  causes  no 
serious  disturbance  in  function  and  can  be  done  with  little  apparent 
deformity.  If  around  the  transplanted  duct  sufficient  connective  tissue 
is  retained  to  insure  its  blood  supply,  no  infection,  short  of  a  gan- 
grenous process,  could  materially  influence  the  result,  for  success  is  in 
no  way  dependent  upon  the  primary  union  of  the  tissues. 

The  operation  may  be  done  in  this  way : 

If  possible,  a  probe  is  passed  into  the  proximal  part  of  the  duct  to 
serve  as  a  guide.  From  a  point  on  the  cheek  directly  over  the  normal 
internal  opening  of  Stenson's  duct  to  a  point  2  centimeters  behind  the 
fistula,  a  curved  incision  is  outlined,  with  its  convexity  downward,  that 
will  pass  2  centimeters  below  the  fistula.  If  the  fistula  is  surrounded 
by  much  scar,  an  incision  must  be  planned  to  eliminate  this  and  to  make 
the  closure  by  flap-sliding.  The  duct  is  exposed  but  not  closely 
stripped.  The  branches  of  the  facial  nerve  are  not  endangered,  as 
they  lie  close  to  the  muscular  fascia.  If  the  incision  extends  back  on 
the  parotid  sheath,  this  is  not  to  be  cut.  The  buccinator  nerve  is  lo- 
cated at  the  lower  border  of  the  duct,  lying  directly  upon  the  masseter 
(Fig.  2i;3).  This  being  avoided,  the  proximal  part  of  the  duct,  with  a 
coating  of  the  fascia  which  surrounds  it,  is  dissected  back  from  the 
masseter  for  1^  centimeters  behind  the  fistula.  If  the  accessory  part 
of  the  gland  which  lies  in  a  finger-like  process  along  the  upper  border 
of  the  duct  is  encountered,  this  is  to  be  elevated  with  the  duct.  Next, 
the  masseter,  fascia,  and  buccal  fat  are  incised  in  the  line  of  the  duct. 


1  Transplantation  of  the  cut  ends  of  the  ureters  has  almost  universally  been 
followed  by  infection  of  the  kidneys.  There  seems  to  have  been  no  observation  of 
this  occurring  after  transplantation  of  the  duct  of  the  parotid.  If  this  gland  is 
liable  to  such  infections,  then  the  operations  that  retain  the  normal  duct  opening 
intact  have  a  distinct  advantage. 


512 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


and  retracted  until  the  buccinator  and  the  masseter  muscles  are  ex- 
posed. The  masseter  muscle  is  defined  and  incised  in  the  line  of  the 
duct,  from  its  anterior  border  to  as  far  back  as  the  duct  has  been  freed. 
The  two  borders  of  the  muscle  incision  are  forcibly  retracted  until  the 
subjacent  buccinator,  and  possibly  the  anterior  border  of  the  ramus, 
are  exposed.  A  finger  passed  into  the  vestibule  of  the  mouth  as  far 
back  as  the  anterior  border  of  the  ramus  will  serve  as  a  guide  in  iden- 
tifying the  buccinator.  If  the  ramus  of  the  jaw  is  exposed,  it  should 
be  freed  of  muscle  upon  its  inner  and  outer  surface,  and  then  sufficient 
bone  removed  (Fig.  401).  If,  in  doing  this,  the  coronoid  process  is 
freed  from  the  ramus,  the  fragment  should  be  removed.  The  bucci- 
nator is  now  exposed  sufficiently  far  back  to  receive  the  end  of  the  duct, 
even  if  cut  off  at  the  gland.  This  is  done  by  passing  the  end  of  the 
duct  through  a  small  hole  in  the  buccinator  and  mucous  membrane,  and 
attaching  the  mucous  border  of  the  wound  to  the  connective   tissue 


Pig.  401.  Exposure  of  the  parotid  duct,  showing  relation  of  the  gland  to  the  buc- 
cinator muscle,  after  division  of  the  masseter  and  removal  of  the  anterior  part  of  the 
ramus. 


surrounding  the  end  of  the  duct  with  a  few  fine  interrupted  tannated 
catgut  sutures.  The  duct  should  be  implanted  in  the  buccinator  suffi- 
ciently far  back  to  cause  no  tension.  If  the  fistula  is  adjacent  to  the 
junction  of  the  gland  and  the  duct,  it  may  be  necessary  to  loosen  the 
buccinator,  undermining  it  from  the  inner  surface  of  the  masseter  and 
buccal  fat  and  drawing  it  up  to  the  gland,  after  the  plan  of  Nicoladoni 
and  Braun. 

The  secretion  of  saliva  in  a  gland  can  be  suppressed  by  ligating  the 
duct,  but  this  operation  has  been  followed  by  such  serious  inflammatory 
reaction,  due  to  infection,  probably  from  bacteria  that  have  already 
found  their  way  into  the  ducts,  that  it  is  not  to  be  recommended.  As 
a  final  means,  the  parotid  gland  can  be  removed,  but  to  do  this  com- 
pletely and  preserve  the  seventh  nerve  is  a  difficult  procedure. 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  513 

TUMORS  OF  THE  SALIVARY  GLANDS. 

Tumors  of  the  salivary  glands  are  of  extreme  interest,  both  on 
account  of  the  peculiar  behavior  of  some  and  because,  in  spite  of  an 
immense  amount  of  work  that  has  been  done  on  them,  the  exact  nature 
of  the  largest  group,  the  so-called  "mixed  tumor,"  is  still  a  matter 
of  dispute. 

Benign  Tumors. — Congenital  enlargements  of  the  sublingual 
and  of  Blandin's  glands  have  been  reported. 

Lipomata,  fibromata,  angiomata,  and  lymphangiomata  of  the  sali- 
vary glands  have  all  been  observed,  but  they  are  of  rare  occurrence. 
They  present  no  special  symptoms  peculiar  to  this  situation  and  are  to 
be  treated  as  are  similar  tumors  in  other  situations,  the  operation  being 
conducted  in  accord  with  the  plans  already  outlined. 

Obstruction  cysts  may  occur  within  a  salivary  gland,  due  to  the 
blocking  of  one  of  the  smaller  ducts,  when  the  accumulation  of  secre- 
tion and  epithelial  detritus  causes  a  cyst  filled  with  a  glary  mucus-like 
fluid.  This  is  a  somewhat  common  occurrence  in  the  sublingual  gland, 
which  constitutes  one  form  of  ranula,  but  is  extremely  rare  in  the  other 
two.  A  cyst  of  this  kind  grows  slowly.  The  symptoms  and  treatment 
of  the  sublingual  cyst  were  described  under  ranula  (see  page  485).  If 
obstruction  occurs  in  a  small  duct  leading  from  a  lobule  in  the  intra- 
oral part  of  the  submaxillary  gland,  this  cyst  would  also  constitute  a 
ranula ;  but  if  the  obstruction  were  somewhere  in  the  body  of  the  gland, 
it  would  bulge  beneath  the  jaw. 

For  cysts  bulging  below  the  jaw  or  into  the  cheek,  a  removal  of  the 
whole  or  part  of  the  gland  might  be  necessary,  as  the  simple  opening 
of  the  cyst  might  be  followed  by  a  salivary  fistula  or  a  recurrence. 

An  old  negro  woman  entered  our  service  at  the  city  hospital  with  a 
tumor  connected  with  the  left  parotid  gland;  it  was  a  long,  finger-like  mass 
extending  down  into  the  neck,  and  near  its  lower  end  was  attached  to  the 
skin.  It  was  elastic,  but  distinct  fluctuation  could  not  be  made  out.  The 
history  she  gave  was  that  two  years  before  a  small  lump  appeared  in  front 
of  the  ear,  and  five  months  before  operation  it  began  to  grow  rapidly.  We 
took  it  for  a  malignant  growth  and  excised  it  with  the  skin  covering,  together 
with  the  neck  tissues  with  which  it  was  in  contact.  The  lower  half  of  the 
parotid  gland  was  removed.  Examination  during  operation  showed  it  to  be 
a  cyst,  2J4  centimeters  in  diameter  and  12  centimeters  long.  It  was  filled 
with  a  clear,  thin,  straw-colored  fluid,  which  unfortunately  was  lost.  Exam- 
ination of  the  cyst  wall  by  Dr.  Harris  showed  it  to  be  not  malignant,  of 
connective  tissue  averaging  about  2  millimeters  thick,  but  nowhere  showing 
an  epithelial  lining. 

Mixed  Tumors. — The  more  common  and  most  important  of  the 
salivary  gland  tumors  is  the  so-called  "mixed  tumor."  It  was  for- 
merly rather  generally  believed  that  these  tumors  were  composed  of 


514  SURGERY  OF  THE  MOUTH  AND  JAWS. 

a  number  of  elements — ^fibrous  and  mucous  tissue,  cartilage,  epithelial 
and  endothelial  cells — and  this  view  is  still  held  by  many.  Butlin, 
Kaufmann,  Nasse,  and  Volkmann  are  of  the  opinion  that  all  of  the 
various  substances  which  are  found  in  them  are  the  product  of  the 
activity  of  endothelial  cells.  Wilms,  who  has  done  some  of  the  most 
important  of  the  recent  investigations,  with  many  of  the  French 
workers,  regards  these  mixed  tumors  as  containing  both  epithelial  and 
connective  tissue  elements.  It  is  usually  conceded  that  they  often  con- 
tain cartilage.  Bland-Sutton  classifies  them  with  the  sarcomata  and 
calls  them  chondrifying  tumors  of  the  parotid.  He  gives  a  description 
of  the  character  of  the  cartilage  cells  that  compose  them,  but  Butlin 
describes  it  as  a  cartilage-like  substance  which  has  surrounded  the  en- 
dothelial cells  and  states  that  it  differs  from  true  cartilage  in  several 
important  particulars.  Their  histological  contents  may  be  remarkably 
diverse.  Bland-Sutton  refers  to  this  as  follows:  "It  is  not  unusual, 
in  sections  from  parotid  sarcoma,  to  meet  with  spindle  cells,  cartilage, 
myxomatous  tissue,  glandular  acini,  and  fibrous  tissue  within  an  area 
of  2  centimeters  square."  Some  are  composed  almost  entirely  of  carti- 
lage or  a  cartilage-like  substance  arranged  in  nodules  bound  together 
with  loose  connective  tissue,  and  these  represent  the  more  slow-growing. 
The  more  rapidly  growing  tumors  consist  of  masses  of  spindle  cells  in 
which  the  cartilage  or  cartilage-like  substance  may  be  interspersed. 
The  tumors  are  liable  to  undergo  mucoid  or  myxomatous  changes,  which 
result  in  softened  spots  or  definite  cysts. 

These  tumors  may  be  congenital  or  may  appear  late  in  life,  but 
they  most  often  appear  between  the  ages  of  fifteen  and  thirty  years  and 
have  a  peculiar  preference  for  the  right  side.  They  are  most  common 
in  the  parotid,  much  less  so  in  the  submaxillary  gland,  and  very  rare 
in  the  sublingual.  They  occasionally  occur  in  the  lacrymal  glands  and 
palate.  They  may  arise  within  the  substance  of  the  gland  or  may  be 
connected  with  it  by  a  stalk,  but  they  are  supposed  to  always  arise 
within  the  gland  capsule.  Parotid  tumors  may  arise  in  front  on  the 
gland  in  the  cheek,  in  the  line  of  the  mouth  slit.  Until  they  acquire 
or  show  a  malignant  character,  they  are  encapsulated,  and  at  this  time, 
unless  situated  very  deep  in  the  parotid,  are  easily  removed.  The 
gland  may  be  found  compressed  and  wrapped  around  a  large  tumor. 
When  not  malignant,  they  are  always  sharply  defined,  but  may  be  very 
nodular.  At  first  they  are  usually  firm,  but  later  may  be  cystic.  In 
one  case  a  small  encapsulated  parotid  tumor  in  a  woman  of  39  years 
was  so  soft  as  to  be  almost  fluctuating ;  and  on  attempting  to  aspirate 
it,  some  tissue  was  drawn  up  into  the  syringe,  which  under  the  micro- 
scope was  identified  as  being  composed  of  endothelial  cells.  This 
diagnosis  was  confirmed  after  the  removal  of  the  tumor.     In  the  sub- 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  515 

maxillary  gland  they  usually  grow  toward  the  neck,  but  in  the  parotid 
the  direction  of  their  growth  will  depend  somewhat  upon  their  original 
starting  point.  A  deep  tumor  may  grow  toward  the  pharynx.  After 
malignancy  once  becomes  evident,  they  infiltrate  rapidly  and  may  ulcer- 
ate through  the  skin.  Death  from  the  malignant  mixed  tumors, 
whether  malignant  from  the  first  or  whether  the  malignancy  seems  to  be 
acquired  later,  results  usually  in  a  few  months.  Death  results  more 
frequently  from  the  local  disturbances — such  as  dyspnea,  starvation, 
hemorrhage,  or  pneumonia — than  from  metastasis  of  the  lungs  and 
other  organs. 

The  most  common  clinical  characteristic  is  the  fact  that  for  a  long 
time  after  they  are  noticed  they  may  grow  slowly  and  then  remain 
stationary  for  years,  only  to  take  on  rapid  and  most  malignant  growth. 
With  this  sudden,  rapid  growth  may  come  metastasis  of  the  lungs  and 
sometimes  of  the  lymph  nodes.  A  few  grow  slowly,  but  continuously, 
without  any  period  of  apparent  rest.  They  are  often  the  size  of  a  nut 
or  small  orange,  but  may  attain  the  size  of  a  man's  head.  When  these 
tumors  have  persisted  for  a  long  time,  and  especially  in  older  people, 
they  may  become  cystic.  These  cysts  may  reach  an  immense  size. 
Hayes  described  one,  of  the  submaxillary  gland,  that  had  existed  for 
thirty  years  in  a  woman  who  died  at  the  age  of  seventy-three,  which 
was  fifty  inches  in  circumference,  weighed  forty-seven  pounds,  and 
which  could  have  been  easily  shelled  out.  They  may  be  tender  in  spots 
or  may  be  painful,  but  are  not  necessarily  so.  When  situated  in  the 
parotid,  they  often  affect  the  seventh  nerve.  Salivation  is  sometimes 
a  very  prominent  symptom. 

The  diagnosis  of  these  tumors  in  their  earlier  stage  is  not  easy, 
except  on  the  supposition  that  a  movable  nodule  situated  within  a  sali- 
vary gland,  not  a  lymph  node,  is  probably  a  mixed  tumor.  With  both 
the  submaxillary  and  the  parotid,  tuberculous  lymph  nodes  may  for  a 
time  simulate  a  tumor ;  but  these  are  usually  multiple,  and  the  behavior 
of  the  nodes  will  usually  serve  to  distinguish  them.  Stone,  which  is 
much  more  common  in  the  oral  part  of  the  submaxillary  gland  or  its 
duct  than  in  the  parotid,  is  less  easily  defined  than  a  tumor  nodule  and 
can  be  diagnosed  by  an  exploring  needle  or  the  x-ray.  After  a  tumor 
in  a  gland  has  grown  slowly  for  months  or  years  and  then  ceases  to 
grow,  the  diagnosis  is  rather  evident.  If,  later,  this  tumor  takes  on 
rapid  growth,  the  diagnosis  is  almost  certain.  When  used  as  a  basis 
for  diagnosis,  the  history  must  be  taken  with  the  greatest  care.  Even 
these  tumors  may  sometimes  be  present  for  a  long  time  before  they  are 
discovered.  Tumors  which  are  malignant  from  the  first  behave  as  do 
malignant  tumors  in  other  situations. 

The  prognosis  of  these  tumors  is  good  if  they  are  removed  while 


516  SURGERY  OF  THE  MOUTH  AND  JAWS. 

they  are  still  encapsulated,  even  if  they  have  already  taken  on  rapid 
growth.  Even  the  benign  tumors  may  continue  to  grow  after  removal, 
for  the  reason  either  that  their  capsule  was  not  completely  excised  or 
that  some  disconnected  nodule  may  have  been  overlooked.  A  malig- 
nant recurrence  after  removal  is  usually  of  extreme  virulency. 

The  treatment  of  all  these  tumors,  unless  on  account  of  their  extent 
and  evident  malignancy  they  are  inoperable,  is  removal  with  capsule. 
If  the  tumor  is  surrounded  by  a  capsule,  it  is  not  necessary  to  remove 
the  gland,  unless  it  is  so  nodular  that  there  is  doubt  of  including  all 
of  its  prolongations.  With  tumors  of  the  submaxillary  gland,  it  is 
probably  safest  and  simplest  to  remove  the  whole  gland  in  every  in- 
stance. (For  the  technique,  see  page  518.)  With  all  but  malignant 
tumors  of  the  parotid  gland,  the  seventh  nerve  must  be  preserved, 
which  complicates  the  operation  (see  page  517).  For  malignant  tumors 
of  any  gland,  the  whole  gland  with  its  capsule  should  be  removed.  If 
the  structure  has  infiltrated  the  capsule,  the  neighboring  structures 
should  be  removed  en  masse.  If  this  cannot  be  done,  the  tumor  is 
inoperable.  If  the  regional  lymph  nodes  are  found  to  be  infected  with 
the  tumor,  they  should  also  be  removed. 

Epithelial  Tumors. — Besides  those  mixed  tumors  in  which  the 
presence  of  epithelial  proliferation  is  still  a  matter  of  doubt,  three  va- 
rieties of  purely  epithelial  tumors  have  been  observed. 

Adenoma. — It  is  probable  that  many  of  the  tumors  which  have  been 
described  under  this  head  belong  to  the  mixed  tumor  variety,  but  pure 
adenomata  have  been  seen  in  all  three  of  the  salivary  glands.  They 
may  be  malignant. 

Carcinoma. — The  pure  adenocarcinoma,  to  which  variety  the 
malignant  adenomata  must  belong,  appear  in  two  clinical  forms  in 
the  salivary  glands,  both  very  rare.  These  are  the  medullary  and 
the  scirrhous  carcinoma.  They  are  both  more  common  in  the  parotid 
than  in  the  other  glands,  though  it  is  possible  that  certain  carcinomata 
of  the  floor  of  the  mouth  may  have  their  origin  in  the  sublingual  gland. 

Histologically  a  tumor  of  the  salivary  gland  is  to  be  considered  an 
epithelioma  when  it  is  observed  that  it  develops  directly  from  the 
glandular  epithelium,  and  that  other  elements  of  the  mixed  tumors 
are  not  present.  The  soft  variety  may  originate  in  young  persons  and 
is  characterized  by  the  abundance  of  cell  growth,  later  by  ulceration. 
In  the  scirrhous  variety,  which  occurs  only  in  elderly  persons,  there  is 
little  tumor  formation  and  marked  retraction  of  the  surrounding  tissues. 
In  this,  it  resembles  scirrhus  of  the  breast.  The  skin  and  tissues  cov- 
ering it  may  be  drawn  inward,  and  the  surrounding  skin  may  be 
thrown  into  folds.  The  soft  tumors  involve  the  lymph  nodes  more  rap- 
idly than  does  scirrhus,  but  with  the  latter  a  chain  of  small,  hard  nodes 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  517 

may  be  found  extending  to  the  clavicle.  Pain  is  a  rather  constant  char- 
acteristic of  all-carcinomata,  usually  more  pronounced  in  the  soft  than 
in  the  hard  variety. 

In  the  parotid  gland  the  seventh  nerve  is  usually  involved,  but  with 
the  scirrhus  the  paralysis  may  be  due  simply  to  pressure.  With  the 
more  advanced  tumors,  there  is  the  usual  picture  of  advanced  carci- 
noma of  the  face  or  mouth  with  impairment  of  the  function  of  all  asso- 
ciated organs. 

The  diagnosis  of  carcinoma  of  the  salivary  glands  in  the  early 
stages,  when  the  diagnosis  is  a  matter  of  the  greatest  importance,  is 
practically  impossible.  If,  after  excluding  syphilis,  tubercle,  and  acute 
septic  inflammations,  all  newly  forming  undiagnosed  tumor  masses  are 
excised  or  subjected  to  a  microscopical  examination,  their  diagnosis 
from  clinical  symptoms  will  be  a  matter  of  less  importance.  Many  of 
the  developing  medullary  carcinomata  have  been  mistaken  for  a  chronic 
or  subacute  inflammation.  Carcinoma  of  branchial  origin  may  simu- 
late carcinoma  of  the  submaxillary  gland,  but  in  the  earlier  stages  this 
impression  would  be  corrected  at  operation.  Lymphosarcoma,  devel- 
oping within  the  parotid,  might  simulate  medullary  carcinoma. 

The  prognosis  is  bad.  If,  however,  in  the  earlier  stages  the  gland 
and  its  capsule  are  removed  with  the  regional  lymph  nodes,  a  cure,  or 
a  long  interval  before  recurrence,  might  be  obtained. 

The  treatment  is  early  excision  of  the  whole  gland,  capsule,  and 
involved  tissue,  en  bloc,  for  a  distance  of  1^  or  2  centimeters,  to- 
gether with  the  regional  lymph  nodes.  If  this  cannot  be  done,  the 
patient  should  not  be  subjected  to  radical  operation.  When  the  odor 
and  discharges  are  offensive,  the  ulcerating  masses  may  be  curetted, 
when  not  too  close  to  large  arteries,  and  packed  with  iodoform  gauze 
saturated  with  balsam  of  Peru. 

In  complete  extirpation  of  the  parotid — if  such  an  operation  is  ever 
complete — where  the  skin  and  fascia  covering  the  gland  are  also  re- 
moved, it  is  remarkable  how  little  distortion  of  the  face  results.  There 
is  an  inability  to  close  the  eye,  but  the  scar  contraction  of  the  cheek 
seems  to  prevent  the  lateral  displacement  of  the  mouth  that  is  typical 
of  Bell's  palsy. 

Invasion  and  Excision  of  the  Parotid  Gland. — In  the  removal  of 
encapsulated  tumors  situated  in  this  gland,  the  most  important  point 
is  the  preservation  of  the  facial  nerve.  During  the  whole  course  of 
the  operation,  the  same  side  of  the  face  should  be  kept  in  view  by  a 
careful  observer,  and  any  twitching  of  the  facial  muscles  should  be 
reported  to  the  operator.  To  facilitate  this,  the  anesthetic  should  be 
administered  by  means  of  an  apparatus  which  hides  no  portion  of  the 
face.     The   incision   may   be  made   directly  over   a   small   superficial 


518  SURGERY  OF  THE  MOUTH  AND  JAWS. 

nodule  in  the  direction  of  the  branches  of  the  seventh  nerve  (Fig.  313), 
but  it  is  better  in  most  cases  to  make  a  semilunar  incision  from  the 
center  of  the  zygoma  curving  backward  just  to  the  tragus  and  behind 
the  border  of  the  jaw.  This  incision  extends  down  to  the  capsule  of 
the  gland  and  allows  the  turning  of  a  flap  that  exposes  it  completely. 
As  the  anterior  border  of  the  gland  is  approached,  care  must  be  ex- 
ercised not  to  cut  the  branches  of  the  facial  nerve  (Fig.  394).  The  in- 
cision for  invading  the  gland  is  to  be  carefully  made  in  the  direction 
of  the  branches  of  the  nerve,  examining  each  bit  of  tissue  before  it  is 
cut  by  grasping  it  sharply  with  an  artery  forceps.  If  a  nerve  is 
pinched,  this  causes  contraction  of  the  muscles  supplied.  When  the 
tumor  nodule  is  encountered,  it  is  to  be  removed  by  blunt  dissection 
that  follows  the  capsule  closely.  After  finding  the  plane  of  cleavage, 
we  have  been  able  to  enucleate  a  tumor  very  quickly  with  the  finger. 
On  the  other  hand,  freely  movable,  small  nodules,  which  are  deeply  sit- 
uated, may  be  very  difficult  to  find  at  operation,  even  though  they  can 
be  easily  felt.  After  removal  of  a  large  mass,  drainage  is  to  be  used. 
This  operation  may  be  followed  by  a  temporary  discharge  of  saliva,  but 
unless  some  larger  duct  has  been  cut,  this  discharge  will  cease. 

Even  with  very  large  tumors  that  are  still  encapsulated,  the  seventh 
nerve  should  not  be  sacrificed.  Though  partly  paralyzed  for  a  long 
time,  function  will  be  restored  when  pressure  is  removed.  With  very 
large  tumors,  to  which  the  relation  of  the  seventh  nerve  is  not  known, 
it  may  be  advisable  to  locate  the  trunk  of  the  nerve,  as  it  emerges  from 
under  the  upper  part  of  the  anterior  belly  of  the  digastric  muscle,  and 
to  follow  it  and  its  main  branches  until  their  relation  to  the  tumor  is 
evident.  After  any  operation  on  the  parotid,  there  is  liable  to  be  a 
temporary  paralysis  of  the  seventh  nerve,  most  marked  in  its  upper 
branches.  It  does  not  appear  for  twenty-four  hours  and  disappears  in 
from  three  to  five  weeks.  Paralysis,  due  to  stretching  the  nerves,  ap- 
pears at  once,  but  disappears  in  time.  Paralysis,  due  to  cutting  the 
nerve,  appears  at  once  and  will  probably  not  disappear. 

Extirpation  of  the  parotid  is  a  more  difficult  operation  and  is  fol- 
lowed by  complete  paralysis  of  the  facial  nerve  of  that  side.  Both 
because  it  is  an  easier  operation  and  because  it  gives  better  results  in 
malignant  growths,  the  gland  should  be  removed  with  as  much  of  its 
capsule  as  is  possible.  Treves  has  made  the  statement  that  a  total 
extirpation  of  the  parotid  is  a  surgical  impossibility,  and  an  examina- 
tion of  its  anatomical  relations  would  tend  to  convince  one  of  the  truth 
of  this  statement.  Much  can  be  gained,  however,  by  a  partial  resection 
of  the  ramus.  An  incision  is  made  from  the  middle  of  the  lower  bor- 
der of  the  zygoma  back  to  the  auricle  and  then  down  in  front  of  the 
tragus  down  to  4  centimeters  below  the  angle  of  the  jaw  or  farther. 


AFFECTIONS  OF  THE  SALIVARY  GLANDS. 


519 


If  the  skin  is  adherent  to  the  tumor,  this  is  included  with  the  latter 
by  an  elliptical-  incision.  The  final  removal  of  an  elliptical  piece  of  the 
skin  is  advisable  in  all  cases  to  overcome  the  retraction  of  the  mouth  to 
the  opposite  side  which  might  follow  cutting  of  the  seventh  nerve. 

The  entire  superficial  surface  of  the  gland  should  be  exposed,  and 
to  do  this,  it  may  be  necessary  to  extend  the  incision  forward  at  the 
lower  border  of  the  zygoma  (Fig.  394).  At  the  lower  pole  the  super- 
ficial veins  are  ligated,  and  by  careful  dissection  carried  just  external  to 


Pig.  402.  Freeing  the  lower  part  of  the  parotid  gland  in  total  excision.  The  sur- 
rounding and  subjacent  structures  are  shown  somewhat  more  plainly  than  appear  at 
operation.  The  digastric  and  stylohyoid  muscles  may  be  drawn  upward  or  downward  to 
expose  the  external  carotid  artery.  (In  these  several  drawings  the  external  ear  is  rep- 
resented drawn  somewhat  backward,  but  the  retractor  is  not  shown.) 


the  capsule ;  the  posterior  bellies  of  the  digastric  and  stylohyoid  muscles 
are  identified  running  downward  and  forward  just  below  the  angle  of 
the  jaw.  The  posterior  portion  of  the  capsule  is  continuous  with  the 
sheath  of  the  sternomastoid,  and  in  order  to  elevate  the  gland  without 
opening  its  capsule,  it  may  be  necessary  to  include  a  layer  of  the 
muscle.  Drawing  the  digastric  and  stylohyoid  muscles  either  forward 
or  backward,  the  external  carotid  can  be  isolated;  and  this  is  to  be 
tied  without  injury  to  the  hypoglossal  nerve,  which  crosses  it  super- 


520 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


ficially  at  this  point  (Fig.  402).  The  external  carotid  having  been 
secured,  the  temporal  artery  and  vein  are  tied  just  where  they  cross 
the  zygoma.  They  He  rather  deep  just  in  front  of  the  ear.  By  sur- 
rounding it  with  an  incision  above  and  at  the  sides  and  catching  every 
vessel  as,  or  before,  it  is  cut,  the  gland  is  made  movable  and  is  par- 
tially withdrawn  from  its  bed,  but  it  is  still  held  by  the  fascia  that  con- 
nects it  with  the  pharynx  and  temporal  bone. 


Fig.  403.  The  ramus  of  the  jaw  displayed  in  total  excision  of  the  parotid  gland. 
The  needle  shown  in  Pig.  262,  has  been  passed  under  the  ramus,  and  the  point  appears 
emerging  through  the  sigmoid  fossa.  It  will  carry  a  wire  saw  into  place,  which  will  cut 
the  ramus  longitudinally. 


To  facilitate  access  to  the  retromandibular  space,  Faure,  recom- 
mends the  excision  of  a  piece,  1  centimeter  wide,  from  the  posterior 
border  of  the  ramus  below  the  neck.  As  simple  a  procedure,  and  one 
that  gives  better  access,  is  to  pass  a  large,  heavy,  curved  needle  under 
the  lower  border  of  the  body  just  in  front  of  the  angle  and  along  the 
inner  surface  of  the  ramus  and  out  through  the  sigmoid  fossa  imme- 
diately in  front  of  the  neck  (Fig.  403).  This  is  followed  by  a  carrier 
with  a  Gigli  saw,  by  which  the  posterior  half  of  the  ramus  with  the  neck 
is  cut  free.     This  piece  of  bone  is  to  be  removed  subperiosteally,  and 


AFFECTIONS  OF  THE  SALIVARY  GLANDS. 


521 


the  condyle  wrenched  out  of  its  socket.  The  cutting  of  the  bone  might 
be  followed  by.  hemorrhage  from  the  inferior  dental  artery,  but  this 
could  be  controlled  as  soon  as  the  section  of  bone  is  removed.  This 
gives  good  access  to  the  deep  part  of  the  gland  and  internal  maxillary 
artery,  under  which  latter  a  ligature  can  be  passed  before  it  is  cut. 
Excision  of  the  condyle  does  not  cause  noticeable  interference  with 
function. 

The  internal  maxillary  artery  and  vein  having  been  secured,  the 
dissection  can  be  continued  backward,  drawing  upon  the  gland   and 


Fig.   404.      Structures   that    are    displayed    after   total   excision   of   the   parotid    gland 
the  posterior  part  of  the  ramus  having  been  removed. 


tearing,  rather  than  cutting,  bands  which  are  not  in  plain  view.  Pos- 
teriorly the  capsule  of  the  gland  must  be  followed  closely,  as  it  is  in 
close  relation  with  the  internal  carotid  artery  (Fig.  404).  At  the  lower 
part  fresh  bleeding  may  be  encountered  when  the  external  carotid  is 
cut,  if  it  was  ligated  below  the  occipital. 

If  the  deep  and  superficial  lymph  nodes  of  the  neck  are  enlarged, 
these  may  be  removed  by  prolonging  the  incision  downward,  but  it  is 
probably  better  surgery  to  take  one  node  for  microscopical  examina- 


523  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tion,  as  this  operation  is  of  such  severity  that  a  complete  removal  of 
the  cervical  lymph  nodes  should  not  be  attempted  at  the  same  time. 
If  the  tumor  proves  to  be  carcinoma,  or  if  the  node  removed  is  affected 
with  new  growth,  a  complete  excision  of  the  lymphatic  tissue  should 
be  made  at  a  subsequent  time.  It  not  infrequently  happens  that  in 
removing  a  carcinoma  in  front  of  or  below  the  ear,  after  almost  com- 
pletely freeing  the  growth,  it  is  found  to  have  deep  attachments  in 
front  of  the  mastoid  process  or  tympanic  plate,  which  seems  to  render 
it  inoperable.  In  such  a  case  something  can  be  gained,  without  adding 
very  much  to  the  operative  risk,  by  dissecting  back  the  concha,  cutting 
the  cartilaginous  part  of  the  external  auditory  canal,  and  removing  the 
anterior  part  of  the  mastoid,  the  tympanic  plate,  and  styloid  process 
with  a  chisel.  If,  in  making  this  part  of  the  excision,  one  undercuts 
the  bone  in  a  plane  superficial  to  the  jugular  bulb,  there  will  be  little 
danger  of  damaging  the  great  vein  or  artery. 

Invasion  and  Excision  of  the  Submaxillary  Gland. — The  sub- 
maxillary gland  is  to  be  exposed  by  an  incision  which  in  a  general  way 
passes  from  near  the  tip  of  the  mastoid  to  and  past  the  middle  of  the 
body  of  the  hyoid.  The  incision  is  curved,  with  the  convexity  down- 
ward, but  its  exact  location  and  extent  will  be  modified  by  the  size  of 
the  tumor.  If  the  skin  is  involved,  this  part  is  to  be  included  in  an 
elliptical  incision.  The  incision  extends  through  the  platysma,  and 
flaps  of  sufficient  size  are  retracted  to  give  a  good  exposure.  If  the 
platysma  is  adherent  to  the  tumor,  part  of  this  muscle  should  be  in- 
cluded in  the  excision.  The  capsule  of  the  gland  is  freed  by  an  in- 
cision at  its  inferior,  anterior,  and  upper  parts.  At  the  posterior  part 
of  the  lower  border  of  the  gland,  the  facial  vein  will  have  to  be  doubly 
ligated  and  cut.  The  gland  is  lifted  from  the  anterior  belly  of  the 
digastric  and  the  mylohyoid  muscles,  when  the  intraoral  part  of  the 
gland  will  be  seen  disappearing  around  the  posterior  border  of  the  mylo- 
hyoid. This  border  of  the  muscle  is  drawn  forward  with  a  hooked 
retractor,  when  the  gland  can  be  severed  from'  the  duct  after  doubly 
clamping  the  latter.  After  the  duct  is  cut,  the  distal  end  is  ligated. 
At  the  posterior  border  the  gland  is  to  be  freed  down  to  the  upper 
border  of  the  digastric  muscle,  from  beneath  the  upper  part  of  which 
the  facial  artery  enters  the  gland.  The  gland  is  now  held  by  the  facial 
artery  and  vein  at  its  upper  posterior  part,  if  they  have  not  already  been 
cut,  and  by  the  facial  artery  which  enters  the  deep  surface  from  behind 
the  upper  part  of  the  digastric  muscle.  The  vessels  are  caught  and 
cut  at  the  border  of  the  maxilla,  and  then  the  deep  trunk  of  the  facial 
artery  is  cautiously  exposed  and  caught,  when  the  gland  can  be  en- 
tirely freed  (Fig.  393).  The  facial  artery  is  tied  with  fine,  strong  silk. 
If  the  forceps  or  ligature  should  slip  from  this  vessel,  free  hemorrhage 


AFFECTIONS  OF  THE  SALIVARY  GLANDS.  523 

would  follow,  which  could  be  partially  controlled  by  digital  pressure  on 
the  common  carotid  against  the  sixth  transverse  cervical  process,  and 
then  by  ligation  of  the  stump  of  the  facial  or  the  external  carotid,  which 
are  exposed  by  drawing  the  posterior  belly  of  the  digastric  and  stylo- 
hyoid muscles  forward  and  upward  with  a  blunt  hooked  retractor. 

If  the  lymph  nodes  are  to  be  removed,  the  submaxillary  and  the 
submental  groups  are  included  with  the  gland,  but  the  removal  of  the 
deep  cervicals  may,  if  deemed  advisable,  be  reserved  for  a  subsequent 
operation.  The  wound  is  to  be  closed  with  drainage  (see  Closure  of 
the  Submaxillary  Wound,  p.  490). 

Invasion  and  Excision  of  the  Sublingual  Gland. — Much  of  this 
gland  lies  immediately  under  the  mucous  membrane  of  the  floor  of  the 
mouth.  Nodules  and  cysts  will  extend  in  the  direction  of  the  mouth. 
They  are  to  be  removed  by  an  incision  made  over  the  most  prominent 
part  and  by  blunt  dissection.  The  tongue  is  to  be  held  out  of  the  way 
by  a  retractor  or  tenaculum  forceps.  The  remaining  wound  is  to  be 
lightly  packed  with  mildly  antiseptic  gauze. 

Malignant  tumors  are  to  be  treated  as  malignant  tumors  of  the 
tongue  and  floor  of  the  mouth  (see  p.  580). 


CHAPTER  XXXVI. 

CONGENITAL  AFFECTIONS  AND  INFLAMMATIONS 
OF  THE  TONGUE. 

The  tongue  may  be  deformed  congenitally  or  from  accident,  oper- 
ation, or  disease. 

CONGENITAL  DEFORMITIES. 

These  are  very  rare.  The  commonest  is  known  as  tongue-tie,  and, 
popular  belief  to  the  contrary,  this  is  unusual.  It  is  due  to  a  short 
frenum,  which  prevents  the  tongue  from  being  protruded  beyond  the 
teeth  or  gums,  and  the  effort  to  do  so  may  cause  the  tip  of  the  tongue 
to  be  notched.  Children  are  often  brought  to  the  surgeon  for  tongue- 
tie  because  they  do  not  talk,  but  this  is  rarely  the  real  reason.  A 
genuine  tongue-tie  may  seriously  interfere  with  sucking,  and  Makuen 
reports  three  rather  marked  cases  of  improvement  in  speech  after  re- 
leasing the  tongue-tie.  When  tongue-tie  is  present,  the  frenum  may 
be  snipped  with  scissors  close  to  the  symphysis  of  the  jaw,  the  tongue 
being  elevated  with  the  first  and  second  fingers  of  the  left  hand.^ 
Only  the  tense  part  of  the  mucous  band  should  be  divided.  Cutting 
too  far  back  may  injure  a  ranine  vein;  fatal  hemorrhage  has  occurred 
from  the  child  sucking  on  the  bleeding  vessel.  Instances  are  also  re- 
ported where  a  tongue  that  was  made  too  free  by  the  operation  turned 
back  into  the  pharynx,  causing  fatal  asphyxia.  Complete  ankyloglossia 
is  a  condition  where  the  whole  body  of  the  tongue  is  bound  down  to  the 
floor  of  the  mouth,  with  obliteration  of  the  sublingual  sulcus.  A  pos- 
sible congenital  instance  of  complete  ankyloglossia  has  been  reported  by 
Duplong. 

In  a  few  instances  the  tongue  has  lacked  sufficient  anchorage  so 
that  it  could  be  turned  back  into  the  pharynx.  Petit  reports  two  cases 
of  fatal  asphyxia  due  to  this  cause.  So  rare  is  complete  congenital 
absence  of  the  tongue,  that  a  case  of  almost  complete  absence,  reported 
by  Jussieu,  has  been  cited  by  most  writers  since.  Occasionally  the 
tongue  has  been  congenitally  cleft  in  the  midline.  This  may  be  ac- 
companied by  median  cleft  of  the  lower  lip  and  jaw.  This  could  be 
repaired  by  simply  freshening  the  edges  and  suturing  the  two  halves. 
ThyrOglossal  dnct  Inmors  and  fistulae  are  presented  in  the  next  chapter. 

1 A  curious  instance  of  the  conservatism  of  instrument  makers  is  shown  In  the 
fact  that  most  grooved  dissectors  are  still  made  with  a  slot  In  the  handle,  devised 
by  Petit,  for  straddling  the  frenum  in  elevating  the  tongue  for  this  operation. 

524 


CONGENITAL  AFFECTIONS  OF  THE  TONGUE.  525 

NODULES. 

A  nodule  or  an  induration  in  the  tongue  may  be  due  to  a  scar  or 
a  foreign  body.  It  may  be  due  to  a  chronic  irritation — such  as  from 
a  sharp  tooth— or  it  may  be  due  to  an  acute  infection.  It  may  be  a 
granuloma — such  as  tubercle,  gumma,  actinomycosis,  etc. — or  it  may 
be  the  early  stage  of  a  tumor. 

INDENTATIONS. 

A  swollen  tongue  may  be  indented  by  the  teeth,  and  when  the 
tongue   remains  permanently  enlarged,   the  indentations   may   persist. 

FISSURES. 

Fissures  on  the  surface  of  the  tongue  are  often  of  extreme  interest. 
A  longitudinal  fissure  in  the  midline  often  suggests  that  the  tongue  is 
wide  for  its  space.  Irregular  shallow  fissures  are  often  seen  in  tongues 
that  have  been  the  seat  of  inflammation.  Fissures  occur  in  acute  in- 
fections, chronic  superficial  glossitis,  tuberculosis,  syphilis,  and  cancer ; 
but  according  to  Butlin,  syphilis  is  the  only  disease  that  will  produce 
deep  fissures  with  permanent  bosses  and  nodules  between  them.  These 
are  frequent  in  tongues  that  have  been  the  seat  of  extensive  gummatous 
infiltration  and  ulceration. 

ULCERS. 

"Simple"  ulcers  arise  upon  the  tongue  apparently  from  various 
causes.  They  are  seen  in  all  kinds  of  chronic  superficial  glossitis  and 
sometimes  in  a  scar.  Occasionally  they  appear  to  be  simply  a  melting 
away  of  the  surface  epithelium.  The  real  reason  why  a  simple  ulcer 
occurs  or  why  it  persists  is  usually  a  matter  of  conjecture.  The  ulcer 
may  become  subacute  or  chronic,  presenting  a  smooth,  red,  glazed 
surface  with  slightly  callous  edges.  They  may  be  irregular  in  shape 
with  fissured  borders.  They  may  be  very  painful  and  sensitive,  es- 
pecially on  taking  irritating  food  or  drink.  The  diagnosis  of  simple 
ulcer  is  usually  easy  from  its  indolent  course  and  lack  of  induration. 
It  may  persist  for  many  months  with  little  change,  but  nevertheless  all 
chronic  ulcerations  should  be  regarded  with  suspicion  when  present  in 
persons  who  have  reached  the  cancer  age,  and  should  not  be  allowed  to 
persist  indefinitely.  If  the  diagnosis  cannot  be  made  otherwise,  an 
examination  should  be  made  by  a  competent  microscopist. 

The  response  to  treatment  of  these  simple  ulcers  is  often  more  or 
less  disappointing.  When  due  to  chronic  superficial  glossitis,  the  plan 
recommended  on  page  531  should  be  adopted.  The  application  daily 
of  a  2  per  cent  solution  of  chromic  acid  or  silver  nitrate  may  stimulate 
epithelization.     A    very    painful    chronic   ulcer    could    be    incised    or 


520  SURGERY  OF  THE  MOUTH  AND  JAWS. 

scraped  in  the  hope  of  obtaining  healthy  active  granulations,  or,  better, 
excised  and  the  edges  of  the  wound  sutured.  Any  chronic  ulcer  that 
becomes  the  seat  of  increasing  induration  in  one  who  has  reached  the 
cancer  age  should  be  regarded  with  grave  suspicion.  In  simple,  as  in 
traumatic,  ulcers  the  general  condition  should  receive  attention. 

Dyspeptic  ulcers  (see  page  349). 

Herpetic  ulcers  (see  page  350). 

Aphthae  (see  page  353), 

Stomatocace  occurs  by  extension  from  the  gum  (see  page  360). 

Noma  may  attack  the  tongue  secondarily  (see  page  355). 

Traumatic  Ulcers. — These  may  be  precipitated  by  any  kind  of 
mechanical  irritation,  most  commonly  by  a  sharp  jagged  tooth,  but 
traumatic  ulcer  is  rarely  entirely  dependent  upon  the  mechanical  irri- 
tation. As  pointed  out  by  Paget,  it  seldom  occurs  when  the  patient  is 
in  good  health,  the  tongue  being  normally  very  resistant  to  such  irri- 
tations. At  the  onset  the  surface  of  the  sore  may  be  covered  by  a 
slough,  the  edges  may  be  sharply  cut,  shreddy  in  places  and  eaten-out, 
and  the  surrounding  tissues  may  be  inflamed.  In  this  stage  it  is 
really  a  phlegmon.  In  the  more  chronic  stage,  the  swelling  in  the 
surrounding  tissues  is  less  marked,  the  edges  are  not  so  sharp,  and  the 
slough  has  disappeared  from  the  base;  but  the  induration  of  its  base 
is  more  marked. 

The  diagnosis  of  simple  traumatic  ulcer  may  present  difficulty. 
The  presence  or  history  of  an  irritation  will  suggest  the  cause,  but  it 
is  to  be  remembered  that  syphilis  or  tuberculosis  may  manifest  itself 
at  the  site  of  a  mechanical  irritation  and  that  cancer  may  arise  in  a 
chronic  ulcer. 

The  phlegmonous  stage  of  a  traumatic  ulcer  will  soon  pass  off 
under  proper  local  and  general  treatment,  and  healing  should  follow 
quickly.  If  in  doubt,  an  examination  for  the  spirochete,  and  a  Wasser- 
mann  test,  should  be  made.  If  due  to  early  syphilis,  it  will  usually  be 
followed  by  other  signs  of  this  disease.  An  ulcerating  gumma  may 
show  more  induration,  and  the  ulceration  is  usually  deeper  than  in  the 
traumatic  ulcer  and  more  resistant  to  all  but  antisyphilitic  treatment. 
A  tubercular  ulcer  is  shallow ;  shows  little  induration,  a  pale  indolent 
surface,  and  usually  the  presence  of  tubercles  near  its  edge.  In  a 
patient  over  forty  years,  any  chronic  ulcer  with  an  indurated  part  that 
persists  after  the  apparent  cause  has  been  removed  should  be  examined 
microscopically  for  carcinoma.  If  the  induration  is  increasing  and 
other  causes  including  syphilis  can  be  excluded,  the  excision  should  be 
made  wide  into  healthy  tissue.  Even  if  carcinoma  is  not  found,  one 
will  have  done  a  good  service  for  the  patient,  as  the  indurations  may 
persist  for  a  long  period  before  cancer  is  demonstrable. 


CONGENITAL  AFFECTIONS  OF  THE  TONGUE.  527 

In  whooping-cough  an  ulcer  may  appear  on  the  under  surface  of 
the  tongue,  due  to  the  pressure  and  friction  on  the  teeth  during  the  act 
of  coughing.  Owing  to  the  proximity  of  large  vessels,  the  ulcer  may 
bleed  freely.  If  such  an  ulcer  threatens  to  assume  serious  propor- 
tions, a  pad  consisting  of  one  layer  of  thick  rubber  dam  fastened  over 
the  incisive  edges  of  the  lower  front  teeth  has  been  recommended.  A 
specially  constructed  silver  shield  might  answer  the  purpose.  Such 
measures,  however,  are  usually  not  very  practical.  In  case  of  serious 
hemorrhage  a  deep  ligature  passed  through  the  base  and  tied  over  the 
bleeding  surface  would  probably  be  efficient.  If  the  ulcer  is  indurated, 
one  or  two  sutures  placed  in  this  way  could  be  tied  over  a  small  pad 
of  iodoform  gauze. 

Dentition  Ulcers. — In  infants  a  small,  shallow  ulcer  sometimes 
appears  where  the  point  of  the  tongue  comes  in  contact  with  an  erupt- 
ing tooth.  Rarely  such  an  ulcer  is  caused  by  an  erupting  molar.  As 
a  rule,  these  ulcers  require  no  special  treatment  except  the  general  care 
of  the  patient,  but  may  occasionally  be  touched  with  a  2  per  cent  solu- 
tion of  nitrate  of  silver. 

INFLAMMATIONS. 

The  mucous  membrane  may  be  the  site  of  an  acute  catarrhal  in- 
flammation similar  to  that  in  other  parts  of  the  mouth.  A  small, 
acutely  inflamed  fissure  or  ulcer  may  appear  near  the  tip,  that  is  very 
painful.  Or,  possibly,  a  single  filiform  papilla  will  become  inflamed 
and,  rising  above  its  fellows,  will  be  subject  to  considerable  irritation. 
Sometimes  a  very  superficial  abrasion  or  fissure  will  be  surrounded  by 
an  extensive  area  of  hard  and  somewhat  tender  induration,  in  which 
case  it  is  no  longer  simply  a  superficial  lesion,  but  a  limited  phleg- 
monous inflammation.  These  are  collectively  referred  to  by  the  pa- 
tients as  "canker  sores"  and  are,  we  believe,  to  be  distinguished  from 
true  aphthae.  In  many  instances  they  are  partly  dependent  upon  some 
digestive  derangement.  The  local  application  of  a  2  per  cent  solution  of 
nitrate  of  silver,  or  quickly  touching  them  with  a  lunar  caustic  stick,  and 
the  use  of  a  permanganate  or  alkaline  antiseptic  mouth  wash  will  usually 
give  relief.  The  bottom  of  a  very  painful  fissure  may  be  incised  after 
applying  a  10  per  cent  cocain  solution,  but  the  habit  of  cauterizing  any 
mouth  lesion  deeply  is  to  be  condemned  on  account  of  the  possibility 
of  the  scar  predisposing  to  cancer, 

(For  acute  phlegmonous  infections  and  abscess  of  the  tongue,  see 
Septic  Infections  of  the  Mouth  and  Neck,  Chap.  XXVIII.) 

RAW  TONGUE  (DYSPEPTIC  TONGUE). 

This  is  an  inflammation  which  is  apt  to  be  recurrent,  depending 
upon  the  derangement  of  the  digestion.     It  is  characterized  by  a  smooth. 


528  SURGERY  OF  THE  MOUTH  AND  JAWS. 

sore,  red  surface,  that  seems  to  be  deprived  of  filiform  papillae.  It  is 
not  exactly  ulcerated;  for  the  excoriation  has  no  depth,  but  the  edge 
is  clearly  defined.  It  usually  covers  a  well-defined  and  considerable 
area  of  the  anterior  part  of  the  dorsum,  while  the  posterior  part  is  al- 
ways thickly  furred. 

It  is  to  be  distinguished  from  acute  scalds  in  that  these  have  a 
definite  history  of  injury  and  heal  in  a  few  days.  The  local  treatment 
consists  in  the  use  of  an  alkaline  antiseptic  mouth  wash.  The  sore- 
ness may  be  lessened  by  painting  with  a  2  per  cent  solution  of  chromic 
acid. 

The  teeth  should  receive  attention,  and  any  digestive  disturbance 
should  be  treated.  When  the  dyspeptic  trouble  is  relieved,  the  tongue 
will  return  to  its  normal  condition. 

ERYTHEMA  MIGRANS   LINGUAE    (GEOGRAPHICAL 

TONGUE). 

This  is  a  rare  disease  which  appears  almost  exclusively  upon  the 
tongues  of  children  and  for  the  most  part  in  subjects  who  are  in  poor 
condition.  It  starts  as  small,  red  patches,  one  or  several,  on  the  dor- 
sum, usually  near  the  tip.  They  appear  smooth,  as  if  the  filiform 
papillae  were  absent,  but  in  which  the  fungiform  papillae  stand  out 
prominently.  The  patch  spreads  as  a  ring  or  oval  with  a  sharply  de- 
fined yellow  border.  When  a  ring  reaches  the  border  of  the  tongue, 
it  continues  around  to  the  under  surface.  If  two  rings  encounter  each 
other,  one  may  grow  at  the  expense  of  the  other,  so  that  one  ends 
abruptly  while  the  other  advances.  The  rings  subside  by  contracting 
until  they  disappear,  sometimes  leaving  the  tongue  slightly  redder  and 
smoother  than  normal. 

Little  is  known  of  its  cause.  Syphilis,  of  course,  has  been  put  for- 
ward, but  this  is  only  a  surmise.  We  once  saw  a  case  in  an  ill- 
nourished  man,  thirty  years  of  age,  with  a  history  of  acquired  syphilis 
and  a  typical  appearing  geographical  tongue,  but  we  were  unable  to 
keep  him  under  observation  long  enough  to  make  an  absolute  diagnosis 
of  erythema  migrans.  It  usually  causes  so  few  subjective  symptoms 
that  its  discovery  is  a  matter  of  accident,  but  sometimes  it  causes  an 
itchy  sensation.  It  is  very  persistent  and  does  not  yield  to  local  reme- 
dies. It  may  persist  for  months  or  years.  One  is  at  perfect  liberty  to 
try  any  local  remedy  which  he  may  please,  but  none  seems  to  have  any 
particular  efifect.  The  general  condition  should  be  given  particular 
attention,  and  all  means  possible  used  to  build  up  the  patient. 
CHRONIC  SUPERFICIAL  GLOSSITIS. 

The  important  characteristic  of  several  forms  of  chronic  superficial 
glossitis  is  a  change  of  form  and  an  arrangement  of  the  epithelial  cells, 
which  may  be  collectively  termed  keratosis.     It  is  this  change  in  the 


CONGENITAL  AFFECTIONS  OF  THE  TONGUE.  529 

epithelium  that  is  of  greatest  interest,  because  it  somewhat  resembles 
the  arrangement  of  the  epithelium  in  the  early  stages  of  tongue  cancer, 
and  cancer  is  not  an  uncommon  sequela.  Keratosis  appears  in  several 
clinical  forms. 

Leucoplakia  or  Leucoma.— This  is  a  somewhat  rare  and  ex- 
tremely chronic  disease  that  affects  most  commonly  the  dorsum  of  the 
tongue,  but  may  appear  on,  or  spread  to,  any  part  of  the  oral  mucous 
membrane,  or  the  red  borders  of  the  lips.  It  appears  in  two  forms  that 
differ  in  appearance,  in  clinical  course,  and  in  pathological  anatomy.  In 
the  first  of  these  the  affected  mucous  membrane  presents  a  smooth 
surface  free  from  papillae,  and  is  of  a  bluish  color ;  the  border  of  the 
patch  may  fade  gradually  into  the  surrounding  normal  mucous  mem- 
brane or  may  be  limited  by  a  sharp  line  of  demarcation.  The  sur- 
rounding mucous  membrane  may  be  normal  or  show  evidences  of  irri- 
tations, and  there  may  be  red  raw  patches  within  the  bluish-white  area 
The  patch  is  often  seamed  with  furrows,  which  may  be  sore  and  may 
later  develop  indurations  of  warty  excrescences.  The  patch  is  usually 
somewhat  pearly  or  opalescent  and  cannot  be  removed  without  leaving 
a  raw  surface.  In  this  form  a  microscopical  examination  of  the  mu- 
cosa shows  that  the  papillae  have  disappeared,  leaving  only  a  layer  of 
corneous  epithelium,  which  is  thinner  than  normal.  There  is  a  pro- 
liferation of  cells  in  the  Malpighian  layer,  with  a  collection  of  leuco- 
cytes immediately  beneath  the  epithelium,  and  the  formation  of  some 
scar  tissue.  In  other  words,  the  patch  appears  to  be  scar  tissue  covered 
by  a  thin  layer  of  epithelium. 

The  other  form  of  leucoplakia  is  one  that  Butlin  describes  as  less 
common,  but  we  have  observed  it  more  frequently  than  the  former.  It 
appears  as  an  opaque,  dead  white,  or  slightly  bluish  or  yellowish  patch, 
which  is  usually  raised  above  the  surrovmding  mucous  membrane,  from 
which  it  is  separated  by  a  sharp  line.  It  is  thicker  toward  the  middle 
than  at  the  edges  of  the  patch,  and  the  outline  is  irregular,  and  often 
deeply  indented.  It  may,  both  objectively  and  subjectively,  feel  dryer 
and  harder  than  the  normal  mucous  membrane.  Later  it  is  apt  to 
become  indurated  and  fissured,  and  the  white  covering  may  be  cast 
ofif  in  places,  leaving  patches  of  red,  raw  tissue.  In  this  variety  of 
leucoplakia,  in  common  with  the  one  first  described,  the  papillae  have 
disappeared,  and  there  are  leucocytes  and  scar  tissue  beneath  the  epi- 
dermis ;  but  here  there  is  an  immense  thickening  of  the  corneous  layer 
which  is  the  cause  of  the  raised  white  appearance.  This  variety  was 
especially  described  by  Sangster. 

In  both  varieties  there  is  a  change  in  the  deepest  layers  of  epithe- 
lium, which  somewhat  resembles  the  first  stage  of  cancer  when  epi- 
thelial cells  begin  to  grow  downward  through  the  basement  membrane. 


530  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Opportunities  for  the  study  of  the  early  stages  of  leucoplakia  have 
been  comparatively  rare.  The  disease  is  then  without  symptoms  and  is 
usually  discovered  by  accident.  There  is  a  condition  designated 
by  Butlin  as  smoker's  patch,  which  is  possibly  one  of  the  early  forms 
of  leucoplakia.  It  is  a  small,  slightly  raised  oval  patch  situated  upon 
the  dorsum  of  the  tongue,  just  where  the  stem  of  a  pipe  habit- 
ually rests  or  it  is  struck  by  a  stream  of  smoke.  The  surface  may  be 
red  and  smooth  and  slightly  depressed  below  the  surrounding  pa- 
pillae. It  later  becomes  covered  with  a  yellowish-white  or  brownish 
crust  that  increases  in  thickness  until  it  peels  off,  leaving  the  original 
smooth  patch.  In  another  form  of  smoker's  patch,  the  surface  is  of 
a  pearly  bluish-white  and  perfectly  smooth.  In  either  case  the  disease 
has  a  tendency  to  spread.  It  may  originally  appear  on  the  buccal 
mucous  membrane  opposite  the  space  exposed  between  the  teeth  when 
the  mouth  is  partially  open.  Smoker's  patch  may  disappear  on  the 
removal  of  the  irritation,  may  remain  stationary  for  years,  or,  as  is 
more  common,  it  may  spread  indefinitely. 

In  persons  who  do  not  smoke,  leucoplakia  may  first  appear  as  a  thin, 
bluish,  filmy  patch,  and  this  may  spread  or  retract,  or  even  disappear; 
but  after  it  has  once  become  well-established,  it  probably  seldom  if 
ever  is  cured.  In  some  cases  the  disease  fluctuates,  disappearing  in 
one  place,  giving  rise  to  the  hope  that  it  has  been  cured,  only  to  break 
out  in  another.  It  may  for  a  long  time  remain  stationary,  only  to  sud- 
denly spread  rapidly  and  involve  possibly  almost  the  whole  of  the  oral 
mucous  membrane. 

Some  patients  are  especially  liable  to  attacks  of  inflammation  in  the 
patch,  or  it  may  die  in  places  and,  being  cast  off,  leave  a  red,  raw,  sore 
spot.  Most  of  the  real  discomfort  that  these  people  sufifer  is  in  con- 
nection with  these  attacks  of  inflammation  or  excoriation. 

Besides  some  special  predisposition,  the  cause  may  be  the  local 
irritation  of  tobacco,  strong  spirits,  high  spices,  hot  foods,  or  mechanical 
irritation.  Butlin  has  observed  that  it  is  more  prevalent  in  those  who 
wear  red  vulcanite  dental  plates  than  in  those  who  wear  the  metal 
ones,  and  he  also,  after  observing  the  disease  in  several  young  women 
who  were  affected  with  hereditary  gout,  assigns  that  as  a  cause.  The 
cause  most  generally  assigned  is  syphilis,  and  although  Gilmer  states 
that  he  Has  never  seen  a  case  in  a  person  who  had  not  had  syphilis, 
there  are  numerous  other  observers  who  report  otherwise.  We  have 
seen  a  number  of  cases  in  which  there  was  neither  a  syphilitic  history 
nor  other  visible  evidence  of  syphilis.  Certain  it  is  that,  if  syphilis  is 
a  cause,  the  leucoplakia  is  a  post  and  not  an  active  syphilitic  manifes- 
tation. The  disease  is  rarely  seen  in  young  persons  and  almost  equally 
rarely  in   women,  but  it  has  been  seen  in   women  under  twenty,   in 


CONGENITAL  AFFECTIONS  OF  THE  TONGUE.  531 

persons  who  do  not  smoke,  in  persons  who  do  not  use  strong  spirits, 
hot  spices,  or  excessively  hot  foods,  and  in  persons  who  are  not  syphi- 
Htics,  so  that  no  one  of  these  can  be  looked  upon  as  the  specific  factor. 

The  diagnosis  of  leucoplakia  is  to  be  made  on  the  conditions  de- 
scribed. It  is  to  be  differentiated  from  syphilitic  mucous  patches  by 
the  acute  onset  of  the  latter  and  the  other  signs  of  acute  syphilis  which 
may  be  present.  Recent  patches  of  leucoplakia  are  not  so  white  and 
are  not  elevated.  It  is  to  be  distinguished  from  postsyphilitic  scars — 
Erb's  scars,  the  thin,  slightly  depressed  opalescent  scars  that  may  remain 
after  secondary  ulcers — by  the  history  of  the  attack  and  by  the  unchang- 
ing size,  shape,  and  character  of  the  scar ;  from  a  syphilitic  psoriasis  by 
the  presence  of  the  same  eruption  on  the  skin  and  other  manifestations 
of  syphilis  present;  from  lichen  planus  by  the  more  pearly  appearance 
and  striated  arrangement  of  the  lichen  and  the  presence  of  the  eruption 
on  the  skin.  Lichen  yields  to  arsenic,  administered  internally,  which  is 
not  the  case  with  leucoplakia. 

Leucoplakia  patches  may  be  present  with  psoriasis.  Lissauer 
found  such  patches  present  in  ten  out  of  fifty  cases  of  simple  psoriasis. 

The  treatment  of  smoker's  patch,  leucoplakia,  and  smooth  tongue 
is  mostly  palliative.  Care  in  diet  and  limitation  or  abstinence  from 
smoking,  with  elimination  of  other  irritants,  will  do  much  to  reduce 
the  intensity  and  number  of  inflammatory  attacks  which  cause  the 
discomfort.  In  the  quiescent  stage,  no  treatment  other  than  abstinence 
from  irritants  is  needed.  Butlin  allows  a  limited  amount  of  smoking, 
but  not  chewing.  In  milder  cases,  a  mouth  wash  of  15  grains  of 
bicarbonate  of  potash,  or  1  or  2  grains  of  chromic  acid  to  the  ounce 
of  water,  is  recommended.  The  alkaline  antiseptic  solution  (N.  F.), 
properly  diluted,  is  always  soothing  to  any  form  of  irritation  of  a 
mucous  membrane.  Some  tongues  are  benefited  by  a  daily  application 
of  balsam  of  Peru.  Butlin  is  partial  to  the  application  of  ointments  in 
all  forms  of  irritation  of  the  mouth  and  recommends  some  simple 
cerate,  like  cold  cream  or  toilet  lanolin.  The  surface  is  first  dried 
with  a  soft  cloth,  and  then  a  little  ointment  is  applied  and  thor- 
oughly rubbed  in  with  the  finger,  or  by  rubbing  the  tongue  against 
the  roof  of  the  mouth.  In  some  cases  one  local  remedy,  and  in  others 
another,  will  be  beneficial ;  but  in  no  case  should  caustics  be  used,  as 
the  resulting  scars  might  further  increase  the  tendency  to  carcinoma. 
We  have  seen  carcinoma  develop  simultaneously  over  the  whole  surface 
of  a  leucoplakia  after  such  treatment.  Constitutional  remedies  are  of 
little  avail.  Even  if  a  leucoplakia  is  dependent  upon  syphilis,  it  is  a 
postsyphilitic  lesion  and  is  not  influenced  for  good  by  mercury.  It  is  the 
belief  of  some  that  it  may  even  be  caused  by  antisyphilitic  treatment. 

The  question  of  excision  will  sometimes  arise.     This  is  not  to  be 


532  SURGERY  OF  THE  MOUTH  AND  JAWS. 

ordinarily  recommended  in  early  cases  unless  they  are  very  small. 
However,  all  persistent  ulcers,  thick  indurations,  and  warty  excres- 
cences should  be  removed  if  possible.  Small  lesions  can  be  excised, 
together  with  a  wedge-shaped  piece  of  tongue,  which  will  allow  the 
immediate  coaptation  of  the  edges  by  suture.  If  it  were  necessary  to 
remove  a  large  surface,  the  effort  might  be  made  to  transplant  a  flap 
graft  from  the  cheek  to  cover  the  defect.  The  disease  is  extremely 
chronic,  and  a  radical  cure  probably  rarely  occurs  except  by  excision. 

Smooth  Tongue  (Moeller's  Glossitis). — There  is  a  form  of 
chronic  glossitis  characterized  by  an  abnormal  smoothness  of  the  whole 
dorsum,  due  to  a  loss  of  the  papillae.  The  mucous  membrane  is  redder 
and  not  of  a  uniform  tint.  The  subjective  symptoms  are  more  marked 
than  in  leucoplakia,  which  it  anatomically  very  closely  resembles,  lack- 
ing only  the  white  color,  though  it  may  be  slightly  bluish.  It  is  more 
easily  irritated,  and  there  is  greater  tendency  to  acute  ulceration.  The 
treatment  is  similar  to  that  of  leucoplakia. 

Ichthyosis. — This  is  the  name  applied  by  Hulke  to  a  certain 
form  of  keratosis  characterized  by  patches  of  a  chronic  hypertrophy 
of  the  papillae,  which  may  become  white  and  quite  horny.  Otherwise 
it  is  of  the  same  nature  as  leucoplakia  and  is  very  prone  to  be  followed 
by  carcinoma.  The  term  verrucula,  which  means  little  wart,  has  also 
been  applied  to  this  condition.  The  treatment  of  ichthyosis  is  similar 
to  leucoplakia,  except  that  salicylic  acid  solutions  may  be  beneficial  in 
keeping  down  the  hypertrophied  papillae. 

Dr.  Mook  recently  showed  us  a  case  of  this  kind  in  his  service  in  the 
Skin  and  Cancer  Hospital,  in  a  syphilitic  who  had  received  salvarsan. 
The  patch  was  becoming  thinner,  especially  at  its  edges,  where  it 
looked  more  like  a  typical  leucoplakia.  In  one  case  in  the  Skin  and 
Cancer  Hospital,  the  ichthyosis  extended  to  the  nasal  mucous  mem- 
brane. 

Black  Tongue  or  Hairy  Tongue. — This  is  another,  less  important 
form  of  keratosis.  It  is  rather  interesting,  because  usually  the  back  of 
the  tongue  becomes  dark  brown  or  black,  and  the  papillae  elongated, 
until  it  looks  as  if  it  were  covered  with  hair.  At  first  the  patch  is 
small,  but  it  extends  slowly  until  a  large  part  of  the  dorsum  is  involved. 
It  usually  lasts  several  months.  It  is  possibly  caused  in  some  cases  by 
a  black  mould  which  has  been  cultivated  by  Ciaglinski  and  Hewelke, 
but  the  color  may  be  due  to  accidental  staining.  It  is  not  believed  that 
this  form  of  keratosis  predisposes  to  cancer;  and  it  is  not  accompanied 
by  the  changes  in  the  corneous  and  deeper  layers,  which  are  found  in 
the  other  forms  of  keratosis.  Lediard  saw  a  case  complicated  by 
cancer,  and  we  once  saw  another.  But  in  both  instances  the  cancer 
was  under  the  tongue  away  from  the  hairy  patch,  and  in  our  case  the 


CONGENITAL  AFFECTIONS  OF  THE  TONGUE.  533 

cancer  antedated  the  patch.  The  patient  may  be  assured  that  the 
disease  will  pass  off.  A  2  per  cent  salicylic  acid  lotion  may  be  applied 
daily,  if  necessary,  to  keep  down  the  excess  of  epithelium. 

GLOSSODYNIA  EXFOLIATIVA. 

This  is  a  form  of  superficial  glossitis  closely  related  to  neuralgia  of 
the  tongue.  It  generally  appears  in  poorly  nourished  anemic  or  neu- 
rotic women.  It  is  characterized  by  red  spots  or  streaks,  that  are  to  be 
observed  by  separating  the  papillae,  and  a  burning  pain,  that  may  be 
very  severe.  The  pain  is  usually  brought  on  by  eating  or  continuous 
speaking.     The  condition  is  chronic,  but  has  quiescent  periods. 

Heretofore,  treatment  has  not  been  a  success.  The  application  of 
increasing  strengths  of  silver  nitrate  gives  relief  by  forming  a  protect- 
ing pellicle.  The  actual  cautery  has  been  recommended  with  the  object 
of  destroying  the  nerve  ends.  If  such  a  case  were  to  come  under 
our  observation  now,  we  would  try  the  injection  of  alcohol  around  the 
lingual  nerve. 

TUBERCULOSIS  OF  THE  TONGUE. 
Tuberculous  infections  of  the  tongue  may  occur  secondary  to  pul- 
monary tuberculosis,  by  direct  contact  from  the  sputum;  it  may  be 
an  extension  of  lupus  from  the  face,  or  due  to  metastasis;  and  it  is 
possible  that  in  some  cases  the  infection  is  primary.  Ordinary  tuber- 
culous infection  of  the  tongue  is  much  more  common  in  men  than  in 
women,  but  in  the  latter  lupus  is  more  prevalent.  This  is  especially 
true  of  girls  and  young  women. 

Tubercles  first  appear  as  small  yellowish  nodules  from  1  to  5 
millimeters  in  diameter,  and  in  this  stage  are  usually  discovered  by  acci- 
dent. They  seldom  attain  large  size  without  ulcerating,  but  occa- 
sionally they  may  grow  to  be  1  centimeter  in  diameter,  or  larger,  and 
still  be  covered  with  normal  mucous  membrane.  They  may  be  multi- 
ple, and  most  commonly  appear  near  the  tip  or  sides  of  the  tongue. 
If  incised,  they  may  show  caseation.  In  place  of  frank  ulceration,  the 
nodule  may  become  fissured. 

Tuberculous  Fissures. — These  are  usually  single,  short,  and  very 
deep  compared  with  their  surface  extent.  The  sides  are  foul  and 
ragged.  The  induration  may  cause  an  elevation  of  the  edges,  which 
has  been  described  as  a  tuberculous  papilloma. 

Tuberculous  Ulcers. — Lupus  is  usually  associated  with  the  same 
disease  on  the  face.  It  shows  more  tendency  to  shrink  and  atrophy 
than  to  break  down,  and  small  tubercles  can  usually  be  found  in  and 
near  its  edges.  It  gives  rise  to  a  purulent  discharge,  but  shows  no 
tendency  to  slough  en  masse  or  to  form  punched-out  ulcers.  It  gives 
little  pain  and  is  very  chronic.     Tuberculous  ulcer  is  the  term  applied 


534  SURGERY  OF  THE  MOUTH  AND  JAWS. 

to  the  more  aggressive  type.  A  tuberculous  ulcer  may  arise  in  a  tuber- 
culous nodule,  in  a  traumatic  ulceration,  or  may  start  without  a  recog- 
nized previous  induration  or  injury.  When  completely  formed  and  not 
sloughing  too  extensively,  it  usually  shows  an  uneven,  pale,  flabby  sur- 
face of  rather  watery  granulations,  or  covered  with  a  grayish-yellow 
secretion.  The  edges  may  be  slightly  redder  than  the  surrounding- 
mucous  membrane.  They  are  usually  sharp  cut  or  beveled,  rarely 
elevated,  everted,  or  undermined,  but  Butlin  states  that  he  has  seen 
tuberculous  ulcers  with  as  much  induration  as  is  found  in  carcinoma. 
At  first  the  ulcer  may  be  indolent  and  neither  painful  nor  tender;  but 
as  the  disease  advances,  tenderness  and  pain  become  marked,  and  the 
patient  declines  from  both  exhaustion  and  lack  of  food. 

The  ulcer  later  advances  rapidly  with  or  without  actual  sloughing, 
and  if  unchecked,  death  usually  takes  place  within  a  few  months.  If 
the  ulcer  should  heal  spontaneously,  as  it  may  do  in  the  early  stages, 
it  usually  returns  later  to  the  same  spot.  (For  diagnosis  and  treatment 
of  tuberculous  lesions  of  the  soft  tissues  of  the  mouth,  see  page  363.) 

SYPHILIS  OF  THE  TONGUE. 

Syphilis  is  one  of  the  most  frequent  diseases  of  the  tongue  and 
next  to  cancer  the  most  important;  yet  this  does  not  warrant  the  very 
common  assumption  that  every  obscure  affection  is  due  to  syphilis. 

Chancre. — The  primary  sore  may  occur  upon  the  tongue,  but 
not  nearly  so  frecjuently  as  it  does  upon  the  lips ;  it  is  much  more  fre- 
quent in  men  than  in  women.  It  occurs  in  two  rather  distinct  clinical 
forms :  the  smooth,  and  the  ulcerated.  The  former  appears  as  a 
smooth,  round  or  oval  excoriation,  not  elevated,  sharply  outlined,  and 
covered  with  a  grayish  purulent  secretion.  It  is  distinctly  indurated 
and  not  ulcerated.  The  ulcerated  chancre  has  the  same  induration, 
but  the  surface  shows  a  shallow  concave  ulceration.  Butlin  describes 
a  rare  fissured  chancre  which  occurs  in  a  fold  of  the  tongue,  but  in  all, 
the  induration  which  has  given  it  the  name  of  "hard"  is  the  same.  In 
every  case  there  is  an  early  and  marked  enlargement  of  the  cervical 
nodes,  usually  of  both  sides,  but  the  enlargement  is  not  always  greatest 
on  the  side  corresponding  to  the  sore. 

Mucous  Patch. — These  may  occur  on  the  dorsum  or  under  sur- 
face, but  more  frequently  on  the  sides  and  tip.  They  are  not  so  com- 
mon on  the  tongue  as  on  the  lip  and  tonsil.  They  are  usually  mul- 
tiple, are  more  common  in  men,  and  rarely  appear  without  other  signs 
of  secondary  syphilis.  The  appearance  varies  according  to  the  loca- 
tion. On  the  dorsum  they  are  usually  round  or  oval,  almost  white, 
and  very  slightly  elevated.  On  the  under  surface,  where  they  are 
exposed  to  no  irritation,  they  are  still  whiter  and  more  elevated.     Unless 


CONGENITAL  AFFECTIONS  OF  THE  TONGUE.  535 

there  is  some  irritation,  there  is  no  redness  of  the  surrounding  mucous 
membrane  in  either  situation.  The  white  layer  may  be  removed,  leav- 
ing a  smooth,  elevated  red  base.  On  the  sides  of  the  tongue  when 
irritated  by  the  teeth,  they  show  more  or  less  ulceration,  which  has  red, 
sometimes  stellate,  outlines.  They  are  rarely  painful  unless  ulcerated. 
After  a  careful  examination  of  the  case  and  of  the  history  of  other 
lesions,  it  is  improbable  that  they  can  be  confounded  with  anything  else. 

Syphilitic  Fissures. — These  may  occur  in  the  secondary  or  the 
tertiary  stage.  The  former  are  almost  always  on  the  border  of  the 
tongue,  due  to  irritation  of  the  teeth.  They  may  occur  in  a  mucous 
patch,  in  which  case  the  fissure  may  be  stellate  and  will  show  sloughy 
borders,  or  they  may  develop  without  a  previous  mucous  patch.  These 
latter  will  show  little  evidence  of  inflammation,  but  are  tender  and 
painful.  These  fissures  may  extend  and  become  ulcers.  Often  there 
is  nothing  in  their  appearance  to  denote  their  specific  cause.  After 
removal  of  irritants — such  as  rough  teeth — ^they  heal  quickly  under 
antisyphilitic  treatment  and  the  daily  local  application  of  a  2  per  cent 
solution  of  chromic  acid ;  but  they  leave  scars,  which  may  be  depressed 
or  may  be  raised  and  show  milk-white  lines  or  patches.  The  fissures 
of  tertiary  syphilis  are  probably  fissures  in  gummata,  although  they  may 
show  little  induration.  They  are  usually  situated  in  the  dorsum  and 
may  be  very  deep.  The  treatment  is  the  same  as  for  gummata,  but 
the  depth  of  the  fissures  should  be  kept  free  fromi  food  and  filth.  They 
leave  deep  fissured  scars. 

Sclerosing  Glossitis — Tertiary  Plaques, — Under  this  head  Butlin 
describes  a  condition,  to  which  attention  was  first  pointed  by  Fournier, 
and  which,  according  to  the  latter  author,  is  often  responsible  for  the 
deep  fissures  that  are  seen  in  old  disfigured  tongues.  Butlin  describes  a 
case  under  his  care  at  St.  Bartholomew's  Hospital,  which,  during  the 
course  of  a  severe  tertiary  syphilis,  showed  plaques  on  the  tongue  on 
several  occasions.  One  on  the  middle  of  the  dorsum  he  describes  as 
being  an  inch  long,  made  up  of  two  separate  oval  plaques,  which  after- 
ward coalesced  and,  increasing  considerably  in  size,  formed  a  single 
plaque  measuring  two  inches  long  and  three  fourths  of  an  inch  across. 
It  rose  almost  abruptly  from  the  dorsum  and  in  its  center  reached  the 
height  of  one  eighth  of  an  inch,  but  was  a  little  less  elevated  at  the 
sides.  It  was  perfectly  smooth  and  of  a  deep-red  color,  but  with  a 
decidedly  purple  tint.  Down  the  center  ran  a  groove  formed  by  the 
meeting  of  the  two  original  plaques.  The  whole  plaque  was  glazed 
and  shiny,  and  was  at  no  point  broken  or  even  cracked.  It  felt  very 
firm,  but  the  firmness  did  not  extend  far  into  the  substance  of  the 
tongue.  In  other  somewhat  similar  plaques  which  had  previously  ap- 
peared on  the  same  tongue  when  the  patient  neglected  treatment,  there 


536  SURGERY  OF  THE  MOUTH  AND  JAWS. 

developed  a  moderately  deep  ulceration,  but  all  would  disappear  under 
proper  treatment. 

According  to  Fournier,  there  may  be  a  superficial  or  deep  sclerosing 
glossitis,  depending  upon  the  depth  of  the  induration.  In  the  super- 
ficial variety  there  are  indurations  which  develop  in  the  derma,  and 
which  feel  like  discs  of  parchment.  They  are  of  a  deeper  red  than  the 
surrounding  mucous  membrane  and  may  be  of  any  size  and  shape. 
They  tend  to  break  down,  forming  fissures  or  ulcers  which,  when 
healed,  leave  milk-white  patches.  The  disease  is  very  chronic  and 
very  painful  in  the  ulcerated  stage.  In  the  deeper  variety  there 
may  be  no  induration  of  the  superficial  part  of  the  mucous  membrane. 
The  surface  of  the  mucous  membrane  is  mammillated  or  lobulated,  and 
like  the  surface  of  the  liver  in  cirrhosis,  ulceration  is  liable  to  result, 
especially  in  the  fissures.  A  rare  form  is  the  syphilitic  macroglossia,  in 
which  the  whole  tongue  is  swollen  and  hardened.  There  is  not,  we 
believe,  evidence  to  show  that  these  various  forms  are  not  due  to 
dififuse  gummata,  and  they  are  often  accompanied  by  ordinary  gummata. 

The  prognosis  of  the  lesion  will  depend  upon  its  extent  and  the 
time  at  which  treatment  was  begun.  After  scar  is  formed,  the  de- 
formity is  permanent,  and  the  resulting  fissures  may  be  the  source  of 
constant  irritation. 

Gumma. — Gumma  of  the  tongue  may  be  superficial  or  deep.  In 
either  situation  they  are  apt  to  be  multiple,  but  the  deep  gummata  are 
often  larger  and  may  persist  longer  without  ulceration.  (For  the 
characteristics  of  gummata  and  gummatous  ulcers  of  the  tongue,  see 
under  Differential  Diagnosis  of  Carcinoma  of  the  Tongue,  page  .50.5.) 

Little  progress  has  been  made  during  several  decades  in  the  treat- 
ment of  late  syphilis,  and  there  are  many  conditions  which  we  had 
come  to  regard  as  permanent  postsyphilitic  lesions.  But  with  the  intro- 
duction of  salvarsan,  many  of  the  supposedly  postsyphilitic  lesions  were 
found  to  clear  up  ;  and  therefore  they  are  to  be  regarded  as  active  and 
not  postsyphilitic  lesions.  As  an  example,  it  would  be  very  appropriate 
here  to  cite  a  case  of  late  syphilitic  glossitis,  reported  by  Sir  Malcolm 
Morris,  that  cleared  up  perfectly  after  the  administration  of  salvarsan. 
We  cite  this  particular  case  because,  in  spite  of  uninterrupted  mercurial 
treatment,  the  tongue  had  become  deeply  fissured,  lobulated,  and 
eroded ;  and  because  the  report  is  accompanied  by  four  colored  litho- 
graphs which  show  the  typical  lesion  before  treatment,  the  apparently 
normal  tongue  forty  days  after  the  injection  of  salvarsan,  and  two 
intermediate  stages.  To  one  who  is  not  familiar  with  the  picture  of 
marked  sclerosing  syphilitic  glossitis,  the  first  illustration  is  well  worth 
seeing.  To  one  who  has  struggled  to  relieve  such  a  condition  with 
the  older  remedies,  such  a  result  seems  little  short  of  marvelous. 


CHAPTER  XXXVII. 

TUiAIORS  OF  THE  TONGUE. 

In  this  chapter  are  presented  the  various  tumors  that  have  been 
found  in  the  tongue,  exclusive  of  carcinoma. 

LYMPHANGIOMATOUS  MACROGLOSSIA. 

Although  not  the  latest  writing  on  the  subject,  Butlin's  description 
in  his  "Diseases  of  the  Tongue"  is,  we  believe,  the  best  clinical  presen- 
tation of  lymphangiomata  of  the  tongue.  Lymphangiomata  appear  in 
the  mouth,  as  either  grouped  or  scattered  vesicles,  which  usually  contain 
clear  fluid,  or  which  may  be  hemorrhagic  from  the  rupture  of  a 
capillary.  Between  the  vesicles  are  seen  bright-red  points  due  to  cap- 
illary loops.  A  patch  of  vesicles  may  be  small  or  cover  a  considerable 
area.  The  vesicles  may  be  so  small  as  to  require  a  hand-glass  for  their 
detection.  We  have  seen  them  on  the  under  surface  of  the  tongue  as 
several  discrete  tufts  that  resembled  papillomata  in  which  no  vesicles 
could  be  seen. 

They  start  as  simple  dilatations  of  the  lymph  spaces  beneath  the 
epithelium.  But  as  these  extend,  the  surface  epithelium  is  thinned ; 
by  extending  downward  and  by  fusion  of  the  spaces,  large  cysts  may 
be  formed.  In  the  tongue  the  growth  of  lymphangiomata  with  their 
various  subsequent  changes  constitutes  lymphangiomatous  macroglossia. 
As  the  disease  progresses,  three  changes  occur  around  these  dilated 
lymph  spaces,  and  in  proportion  to  the  predominance  of  each  will  the 
condition  in  advanced  cases  depend. 

(A)  The  blood  vessels,  both  arteries  and  veins,  that  surround  the 
lymph  spaces  increase  in  size  and  become  thin-walled,  and  by  rupturing 
into  the  cystic  spaces,  fill  them  with  blood.  By  this  means  certain 
h^mphangiomata  will  be  found  to  contain  fluid  stained  with  blood  or 
solid  blood  clots. 

(B)  An  inflammation  occurs  around  the  lymph  spaces  which  re- 
sults in  the  formation  of  connective  tissue.  These  attacks  of  inflamma- 
tion are  recurrent,  but  each,  when  it  subsides,  leaves  the  tissues  more 
infiltrated  than  before.  The  clinical  history  of  a  lymphangioma  is 
marked  by  these  repeated  inflammatory  attacks.  The  connective  tissue 
infiltration  around  the  cysts  gives  them  a  firm  tumor-like  base  which  is 
one  of  their  diagnostic  features.  An  old  lymphangioma  attains  great 
hardness.     As  the  connective  tissue  increases,  by  its  pressure  it  causes 

537 


538  SURGERY  OF  THE  MOUTH  AND  JAWS. 

atrophy  of  the  muscle  fibers  so  that  the  enlarged  tongue  contains  less 
muscle  than  normal. 

(C)  Round  cells  collect  in  the  deep  connective  tissue  spaces  which 
are  not  replaced  by  new  connective  tissue,  but  tend  to  form  new  growth 
which  may  terminate  in  a  small  round  cell  sarcoma  or  lymphosarcoma. 

Lymphangiomata  are  usually  congenital,  but  may  not  show  active 
enlargement  until  puberty  or  later.  They  are  apparently  not  always 
congenital,  for  they  have  followed  injury  or  operations  upon  the  tongue 
or  mouth,  even  so  slight  as  the  cutting  of  the  frenum.  They  have 
occurred  in  conjunction  with  cystic  hygroma  and  true  angioma.  The 
enlargement  of  the  tongue,  though  progressive,  is  from  time  to  time 
accentuated  by  the  acute  attacks  of  inflammation.  At  first  the  tongue 
may  simply  present  vesicles  on  some  part  of  its  surface  while  its  sub- 
stance is  soft.  When  the  vesicles  rupture,  they  may  leave  tender 
places  that  cause  a  disinclination  to  take  food.  Later,  as  the  size  in- 
creases, the  tongue  can  still  be  retained  within  the  mouth,  but  it  is 
evidently  too  large.  It  causes  impairment  of  speech  and  difficulty  in 
eating.  When  it  constantly  protrudes,  the  saliva  dribbles,  the  teeth 
become  coated  with  tartar,  and  the  mouth  is  foul.  The  tongue  is  sub- 
ject to  attacks  of  superficial  glossitis  with  ulceration,  and  becomes  dry 
and  fissured.  The  teeth  become  displaced,  and  the  palate  and  jaws 
deformed.  When  the  enlargement  occurs  during  the  period  of  growth 
of  the  bones,  the  deformity  of  these  is  much  more  marked.  The  whole 
tongue  may  be  the  seat  of  the  angioma,  but  more  commonly  it  is  limited 
to  some  part.  Aside  from  the  swelling  that  follows  acute  inflamma- 
tory attacks,  the  process  is  slow  of  development,  requiring  months  or 
years  to  reach  an  advanced  form.  The  diagnosis  is  made  from :  the 
presence  of  cysts  containing  serum '  or  blood,  which  usually  have 
some  induration  around  their  base;  and  the  chronic  progressive  enlarge- 
ment, which  is  usually  very  firm.  If  a  section  is  removed  for  micro- 
scopical examination,  it  should  be  done  only  after  placing  a  chain  of 
sutures  around  the  site  of  the  proposed  excision,  as  the  subsequent 
bleeding  may  be  very  free.  Even  from  the  needle  holes  very  free 
bleeding  may  occur,  but  it  is  mostly  capillary  and  will  cease  with  gentle 
suture  pressure.  It  is  to  be  distinguished  from  nevus  by  the  presence 
of  serum  in  some  vesicles  and  the  character  of  its  progress ;  from  muci- 
parous cysts  by  the  induration  at  the  base  of  the  vesicle. 

Treatment. — This  should  be  excision  of  the  affected  area  made 
through  healthy  tissue.  When  the  disease  involves  the  whole  tongue, 
there  is  little  question  that  a  total  excision  should  be  made,  for  it  is 
progressive  and  will  continue  to  grow  unless  removed.  If  so  radical 
a  measure  does  not  seem  advisable,  a  wedge-shaped  excision  should  be 
made  of  sufficient  tissue  to  allow  the  tongue  to  be  retained  in  the  mouth. 


TUMORS  OF  THE  TONGUE.  539 

The  excision  should  be  made  as  early  as  practical,  because  the  longer 
the  growth  persists  the  more  tissue  will  have  to  be  sacrificed.  If  the 
tumor  shows  no  present  inclination  to  grow,  as  may  be  the  case  in 
infants  and  young  children,  excision  can  be  postponed  until  after  in- 
fancy and  the  child  is  in  good  condition,  but  it  might  be  necessary 
to  do  the  operation  immediately  after  birth  in  order  to  preserve  life. 

It  is  to  be  strongly  recommended  that  the  excision  be  made  with 
a  knife  or  scissors  with  immediate  suture.  While  this  method  would 
appear  most  reasonable  and  practical,  still  the  actual  cautery  has  been 
recommended.  Butlin  sounded  a  warning  against  the  use  of  the  actual 
cautery  in  the  tongue  in  any  condition,  on  account  of  the  danger  of 
the  scar  being  a  predisposition  to  cancer.  Moreover,  in  lymphangioma 
the  disease  has  been  made  worse  by  its  application. 

In  making  an  excision  with  a  knife  or  scissors,  hemorrhage  is  a 
serious  consideration.  One  lingual  artery  could  be  tied  for  a  unilateral 
growth,  but  a  simultaneous  ligation  of  both  linguals  might  not  be  safe. 
One  lingual  could  be  tied,  and  the  opposite  carotid  temporarily  com- 
pressed. If  it  were  evident  that,  even  after  splitting  both  cheeks  in 
the  line  of  the  mouth,  the  growth  could  not  be  surrounded  by  hem- 
orrhage controlling  sutures,  the  tongue  could  be  removed  by  Kocher's 
normal  excision  (see  page  588). 

SIMPLE  MUSCULAR  MACROGLOSSIA. 

This  occurs  congenitally,  either  by  itself  or  in  conjunction  with 
other  hypertrophies  of  muscle  and  bone.  A  combination  of  muscular 
and  lymphangiomatous  hypertrophy  has  been  reported  by  Zeisler.  The 
muscular  tissue  may  be  normal  in  its  microscopical  appearance,  or  the 
fibers  may  be  increased  in  number  and  in  size.  Simple  muscular 
hypertrophy  of  the  tongue  is  usually  associated  with  defective  intellect, 
and  as  a  rule,  no  treatment  is  indicated ;  but  the  size  of  the  tongue  can 
be  lessened  by  a  V-shaped  excision.  Besides  these  usually  congenital 
conditions,  the  tongue  may  become  temporarily  or  permanently  en- 
larged as  the  result  of  septic  infection,  syphilis,  or  mercurialism. 

TUMORS  OF  THE  BLOOD  VESSELS. 

Aneurysm,  in  its  various  forms,  may  occur.  Capillary  nevi,  similar 
to  those  seen  upon  the  skin,  composed  of  a  mass  of  dilated  capillaries, 
occur  on  the  tongue,  cheeks,  and  lips.  They  are  usually  congenital, 
but  may  be  acquired.  Upon  the  tongue  they  appear  as  small,  slightly 
elevated  patches,  the  size  of  a  pea  or  smaller;  on  the  buccal  surface 
of  the  cheek  they  may  be  larger — here,  or  upon  the  lip,  they  may  be 
continuous  with  a  wine  spot  upon  the  face.  They  are  of  a  bluish  color, 
darker  than  their  surroundings,  and  at  the  periphery  an  interlacing 


540  SURGERY  OF  THE  MOUTH  AND  JAWS. 

of  small  vessels  is  visible.  They  may  be  single  or  multiple  or  may 
converge  into  the  venous  cavernous  form  of  angioma. 

Cavernous  Angioma. — The  venous  or  cavernous  angioma  is 
composed  of  a  mass  of  dilated  veins  and  is  either  sharply  circumscribed 
or  merges  into  the  capillary  form.  The  circumscribed  cavernous 
angioma  possesses  a  distinct  efferent  artery  and  afferent  veins  and 
does  not  communicate  with  the  neighboring  capillaries.  They  occur 
singly  or  in  groups  and  show  lumps  or  ridges  of  distended  veins,  of  a 
dark  bluish  or  greenish-black  color,  which  project  slightly  above  the 
surface  and  may  extend  deeply  into  the  subjacent  tissues.  They  are 
very  compressible,  but  immediately  refill  when  pressure  is  released. 
When  the  head  is  held  low  or  pressure  is  put  upon  the  deep  jugular 
veins,  or  when  anything  else  occurs  that  retards  the  venous  return. 
they  become  more  distended  than  usual.  Butlin  states  that  some  of 
these  venous  angiomata  are  not  compressible,  but  feel  like  tense  elastic 
cysts.  We  have  never  observed  such  a  condition  nor  do  we  understand 
the  mechanism  that  can  produce  this  symptom — unless  they  contain  a 
clot  or  have  been  inflamed  as  the  result  of  injury  or  infection.  They 
are  usually  congenital  in  origin,  often  growing  later  from  capillary 
nevi,  but  they  may  arise  apparently  independently  of  a  congenital 
angioma. 

Venous  and  capillary  angiomata  are  of  clinical  importance,  both 
because  of  their  liability  to  hemorrhage  and  because  they  may  spread 
indefinitely,  converting  all  tissues  of  a  large  area  into  a  swollen,  dis- 
colored mass  of  thinly  covered  blood  vessels.  In  the  tongue  they  are 
usually  not  large,  though  there  are  a  few  instances  on  record  in  which 
the  whole  tongue  was  converted  into  a  greatly  enlarged  cavernous  mass. 
One  of  these,  preserved  in  the  Hunterian  Museum  of  London,  old  cata- 
logue No.  2767,  consists  of  what  was  the  anterior  two  thirds  of  the 
tongue,  which  was  removed  from  a  man  by  Butlin,  because  it  had  been 
converted  into  a  cavernous  angioma.  It  was  of  congenital  origin. 
Parts  of  the  lips,  cheeks,  and  floor  of  the  mouth  and  face  may  be  con- 
verted into  a  soft,  compressible  tumor  of  a  bluish  color  on  its  mucous 
surface  and  slightly  more  reddish  on  the  external.  Nowhere  are  these 
extensive  extending  nevi  sharply  marked  off  from  the  surrounding 
tissue.  When  situated  under  the  tongue  in  the  floor  of  the  mouth, 
cavernous  angioma  has  been  mistaken  for  ranula.  Besides  being  the 
source  of  occasional  copious  hemorrhages,  started  by  injury  or  by  simple 
rupture  of  the  thin-walled  vessels,  these  nevi  may  become  infected  and 
suppurate.  In  the  smaller  tumors,  especially  of  the  capillary  nevi,  this 
may  be  followed  by  obliteration,  but  in  the  more  extensive  cavernous 
ones  it  constitutes  a  serious  complication.  Cavernous  nevi  are 
sometimes  obliterated  by  fatty  degeneration. 


TUMORS  OF  THE  TONGUE.  541 

Varicose  veins  filling  the  floor  of  the  mouth  are  to  be  distinguished 
from  cavernous  angioma  by  their  symmetrical  bilateral  distribution,  and 
by  the  presence  of  enlarged  normally  situated  veins  on  the  under  surface 
of  the  tongue  and  inner  surface  of  the  lip.  The  varicosity  of  the  veins 
in  the  floor  of  the  mouth  may  be  so  extensive  as  to  raise  the  mucous 
membrane  to  the  level  of  the  ginvivae.  They  empty  when  compressed 
and  immediately  refill  in  the  same  way  as  does  a  cavernous  angioma. 
They  might  bleed  freely  if  injured,  but  we  have  never  observed  any 
serious  symptoms  caused  by  them. 

Diagnosis. — The  arterial  and  aneurysmal  tumors  are  distinguished 
by  their  pulsation.  With  aneurysms  the  thrill  may  be  felt.  A  history 
of  a  penetrating  injury  may  suggest  the  presence  of  an  aneurysmal 
varix.  In  cirsoid  aneurysms  the  enlarged  arteries  have  been  felt  under 
a  mass  of  varicosed  veins.  The  diagnosis  of  capillary  and  venous  nevi 
is  usually  extremely  simple,  but  if  indurated,  it  is  desirable  to  determine 
whether  the  induration  is  due  to  some  former  injury  or  infection,  or  to 
the  involvement  of  the  lymphatics.  The  latter  condition  would  con- 
stitute lymphangioma.  In  pure  hemangiomata  indurations  due  to  past 
injury  or  infection  are  usually  sharply  localized,  while  the  inflammation 
that  often  accompanies  lymphatic  dilatation  causes  a  more  diffuse  hard- 
ness. With  the  lymphatic  angiomata,  the  characteristic  blebs  are 
usually  present.  From  varicose  veins  a  cavernous  angioma  is  to  be 
distinguished  by  the  symptoms  already  mentioned. 

Tre;atmi;nt. — As  a  general  proposition,  all  angiomata  should  be 
destroyed  or  removed.  While  small  nevi,  as  such,  really  need  no  treat- 
ment ;  still,  when  small,  their  removal  is  a  very  simple  matter,  and  their 
tendency  to  enlarge  at  any  time  must  not  be  ignored.  At  least,  they 
should  be  destroyed  or  removed  as  soon  as  they  begin  to  extend.  Many 
blood  vessel  tumors  have  been  destroyed  by  the  injection  of  irritating 
substances  into  them,  but  with  the  exception  of  boiling  water  in  the 
large  diffuse  cavernous  angiomata,  the  injection  treatment  is  to  be  con- 
demmed  on  account  of  the  danger  of  both  sloughing  and  embolism. 
Besides  the  injection  of  boiling  water  into  certain  selected  cavernous 
tumors,  there  are  three  lines  of  treatment  that  may  come  within  the 
domain  of  good  surgical  practice:  (A)  the  ligation  of  vessels;  (B) 
the  destruction  of  the  mass  by  acupuncture;  and  (C)  the  excision  of  the 
mass,  either  by  dissecting  it  out  or  by  cutting  through  the  surrounding- 
healthy  tissue.  Other  things  being  equal,  excision  is  the  best  practice. 
Aneurysmal  enlargements  have  been  treated  by  the  proximal  ligation 
of  one  or  several  arteries — such  as  the  lingual  and  facial — first  on  one 
side  of  the  face  and  later  upon  the  other.  Whenever  possible,  it  is 
better  to  excise  the  mass  of  vessels,  but  before  this  is  done,  the  arterial 
blood  supply  is  to  be  controlled.     In  some  situations  this  can  be  done 


542  SURGERY  OF  THE  MOUTH  AND  JAWS. 

bv  grasping  the  base  or  surrounding  tissue  with  one  or  several  compres- 
sion forceps,  or  by  temporarily  surrounding  the  growth  with  inter- 
locking compression  sutures.  These  sutures  may  include  parts  of  the 
face,  the  body  of  the  jaw-bone,  or  the  tongue.  These  compression 
sutures  are  best  made  of  elastic-band  rubber  and  should  be  drawn  only 
sufficiently  tight  to  control  the  blood  supply,  and  not  crush  the  tissues. 
For  the  anterior  two  thirds  of  the  tongue  and  the  floor  of  the  mouth, 
the  blood  supply  may  be  controlled  as  follows : 

Just  anterior  and  internal  to  the  angle  of  the  jaw,  close  to  the  inner 
surface  of  the  bone,  a  small  submaxillary  skin  incision  is  made,  and 
through  this  a  probe-pointed  needle  or  a  stiff  probe  is  forced  through 
the  posterior  part  of  the  floor  of  the  mouth  just  in  front  of  the  anterior 
faucial  pillar,  using  the  finger  on  the  inside  as  a  guide.  By  means  of 
this  probe  or  needle,  two  silk  carriers,  one  white  and  the  other  black, 
are  drawn  through  the  floor  of  the  mouth,  the  internal  ends  being 
brought  out  of  the  mouth  and  fastened  to  the  submaxillary  ends  by  an 
artery  forceps.  This  part  of  the  operation  is  repeated  on  the  other 
side.  By  means  of  the  two  white  carriers,  a  fine,  strong,  elastic  tube  or 
band  is  made  to  surround  the  pharyngeal  surface  of  the  tongue,  and 
skin,  just  above  the  hyoid  bone.  This  ligature  includes  the  lingual  and 
the  facial  arteries.  The  internal  end  of  each  of  the  black  silk  carriers 
is  passed  through  the  cheek,  and  by  means  of  these,  constricting  bands 
may  be  made  to  surround  the  remaining  tissue  of  the  floor  with  the  body 
of  the  jaw  on  each  side.  The  distal  end  of  the  facial  arteries  can  be 
controlled  by  grasping  the  cheeks  with  flexible-bladed  forceps.  While 
tightening  the  band  that  surrounds  the  tongue,  the  body  of  the  latter 
should  be  drawn  forward,  and  the  band  placed  as  far  back  as  will  be 
permitted  by  the  faucial  pillars.  By  doing  this,  the  body  of  the  tongue 
will  be  in  front  of  the  constricting  band. 

Another  plan  is  to  ligate  certain  arteries  of  one  side — such  as  the 
facial,  lingual,  and  distal  part  of  the  external  carotid — while  the  external 
carotid  is  temporarily  compressed  upon  the  other.  This  will  partially 
control  it.  After  controlling  the  blood  supply,  the  tumor  is  cut  down 
upon  and  dissected  out.  Both  aneurysms  and  sharply  outlined  caver- 
nous angiomata  can  be  removed  in  this  manner.  With  aneurysms,  the 
cut  ends  of  the  individual  arteries  will  have  to  be  caught  and  ligated 
before  completely  releasing  the  control  ligatures.  With  venous  tumors, 
the  cut  end  of  the  afferent  artery  can  be  controlled  with  sutures. 
From  the  lips,  sides  of  the  tongue,  or  tip  of  the  tongue  angiomata 
can  be  removed  by  V-shaped  excisions   (Fig.  409). 

Small,  and  even  large,  nevi  have  been  destroyed  by  the  electric 
needle. 


TUMORS  OF  THE  TONGUE.  543 

CARTILAGINOUS  TUMORS. 

Cartilaginous  tumors,  or  cartilage-like  tumors,  may  occasionally 
arise  in  the  tongue  in  connection  with  the  median  septum,  or  secondly 
in  the  endotheliomata.  They  are  exceedingly  rare.  The  osseous  and 
the  true  cartilaginous  tumors  are  congenital  and  can  occur  only  in,  or 
near,  the  median  line,  and  are  of  extremely  slow  growth.  Endothelio- 
mata that  produce  a  cartilage-like  substance  are  also  of  slow  growth,  but 
like  mixed  tumors  of  the  salivary  glands  they  may  become  active.  They 
should  be  removed  if  they  cause  symptoms  or  show  any  activity,  but 
it  is  more  probable  that  they  will  be  removed  to  make  sure  of  their 
character.  Amyloid  deposits  on  the  tongue  have  been  reported.  They 
occur  in  persons  suffering  from  amyloid  degeneration,  and  have  usually 
been  situated  on  the  base  of  the  tongue  in  front  of  the  epiglottis. 

LIPOMA. 

Besides  those  that  occur  in  or  under  the  tongue  in  the  midline  and 
which  grow  into  the  floor  of  the  mouth,  lipomata  have  been  reported 
as  occurring  singly  at  the  anterior  part  of  the  border  of  the  tongue; 
and  multiple  lipomata  of  the  tongue  have  been  observed  in  old  men. 
Except  those  that  occur  in  the  midline  beneath  the  tongue,  the  tumors 
lie  immediately  under  the  mucous  membrane,  which,  although  thinned 
and  stretched  and  devoid  of  papillae,  is  movable  over  the  growth. 
Usually  the  yellow  color  has  been  apparent  through  the  thin  mucous 
membrane.  The  superficial  tumors  are  movable,  can  be  displaced 
by  finger  pressure,  and  their  lobulated  structure  is  palpable.  The  cen- 
tral lipomata  are  probably  always  congenital  and  derived  from  the 
median  septum  of  the  tongue.  They  are  likely  to  contain  both  fibrous 
tissue  and  cartilage.  These  may  grow  between  the  muscles  until  they 
appear  beneath  the  chin.  These  tumors  seldom  cause  ulceration,  and 
even  when  as  large  as  a  small  orange,  they  are  remarkably  free  from 
subjective  symptoms.  Excepting  those  which  are  congenital,  they  have 
usually  appeared  in  middle  or  later  life.  They  are  to  be  distinguished 
from  soft  sarcomata  chiefly  by  their  chronicity,  requiring  as  they  do 
many  years  to  attain  any  considerable  size.  (The  differential  diagnosis 
of  median  lipomata  from  ranulae  and  dermoids  is  given  on  page  486.) 

The  treatment  of  lipomata  that  have  attained  a  sufficient  size  to 
attract  the  patient's  attention  is  removal.  The  extirpation  of  submu- 
cous lipoma  is  very  simple.  Under  local  anesthetic  an  incision  is  made 
down  to  or  into  the  tumor.  The  latter  is  grasped  with  forceps  and 
drawn  forcefully  out  of  its  bed.  As  this  is  done,  its  attachments  to  the 
surrounding  connective  tissue  are  cut  with  knife  or  scissors.  If  the 
tumor  is  distinctly  peduirculated,  it  may  be  removed  by  an  elliptical 
incision  at  its  base.     The  wound  may  be  immediately  closed  by  deep 


544  SURGERY  OF  THE  MOUTH  AND  JAWS. 

sutures  that  include  its  full  depth.     (The  sublingual  lipomata  are  to  be 
approached  as  outlined  in  Tumors  of  the  Floor  of  the  Mouth,  page  488.) 

FIBROMA. 

These  occur  in  two  forms :  the  soft  tumors  that  are  especially  liable 
to  become  pedunculated  and  are  often  known  as  lingual  polypi,  and  the 
hard  tumors  that  are  more  apt  to  remain  intramuscular.  The  former  are 
frequently  situated  on  the  dorsum  of  the  tongue  and  are  often  multiple. 
It  is  stated  that  they  are  apt  to  follow  a  chronic  inflammation  as  do 
polypi  of  the  nose.  These  soft  tumors  grow  slightly  more  rapidly  than 
do  lipomata  and  do  not  possess  their  yellow  color,  but  otherwise  re- 
semble them  closely.  The  hard  tumors  are  much  rarer  than  the  soft. 
Neither  variety  gives  subjective  symptoms,  except  those  due  to  their 
size.     The  treatment  is  the  same  as  of  lipoma. 

KELOID. 

Keloid  of  the  tongue  has  very  rarely  been  observed.  Butlin  cites 
two  cases :  one,  reported  by  Sedgwich,  occurring  spontaneously  in  a 
little  girl,  the  tongue  resembling  the  site  of  surgical  operation ;  another, 
of  supposed  keloid,  following  an  injury  of  the  tongue,  in  a  young  man 
under  the  care  of  Mr.  Morrant  Baker.  The  present  treatment  of  keloid 
is  the  use  of  radium  or  the  x-ray. 

TUMORS  AND  CYSTS  OF  THE  THYROGLOSSAL  TRACT. 
(LINGUAL  GOITER.) 

The  demonstration  by  His  of  a  tract  of  tissue  extending  from  the 
pyramidal  lobe  of  the  thyroid  gland  to  the  foramen  cecum  has  made  pos- 
sible the  explanation  of  tumors  and  cysts  occurring  near  the  foramen 
cecum  or  the  hyoid  bone,  that  contain  elements  belonging  to  the  thyroid 
gland. 

Thyroglossal  Tract  Tumors  Near  the  Foramen  Cecum. — These 
may  be  cystic  or  very  soft  solid.  All  of  these  tumors  are  of  congenital 
origin,  but  they  may  not  develop  sufficiently  to  cause  symptoms  until 
later  in  life.  Usually  they  are  noticed  about  puberty,  but  may  not  give 
symptoms  until  late  in  life.  Those  occurring  about  the  foramen  cecum 
are  usually  somewhat  sessile  and  vary  in  size  from  a  pea  to  a  hen's  egg. 
When  large,  they  project  backward  toward  the  pharynx  and  forward 
to  a  less  extent,  though  another  tumor  may  occur  above  the  hyoid  that 
projects  beneath  the  chin.  Such  a  case  has  been  reported  by  Bernays. 
They  are  almost  always  soft  and  not  indurated,  but  the  first  case  re- 
ported, which  was  by  R.  Wolff  before  the  German  Surgical  Con- 
gress, in  1882,  is  described  as  being  hard. 

They  are  usually  of  a  dark  color,  covered  with  stratified  epithelium 
and  large  veins.     They  are  enclosed  in  a  distinct  capsule,  and  their 


TUMORS  OF  THE  TONGUE.  545 

substance  shows  mature  or  immature  typical  thyroid  gland  tissue. 
Where  cysts  occur,  they  are  lined  by  ciliated  epithelium.  The  tumors 
are  very  vascular  and  may  contain  hemorrhages.  Occasionally  they 
are  so  vascular  as  to  be  described  as  blood  cysts.  Besides  the  disturb- 
ances that  are  dependent  upon  the  size  and  location  of  the  tumor,  the 
most  constant  symptom  is  hemorrhage  into  the  mouth,  due  to  rupture 
of  the  veins  that  almost  invariably  cover  it.  It  occurs  most  commonly 
in  girls  and  women.  The  diagnosis  is  to  be  made  on :  the  location  of 
the  tumor;  its  slow  growth,  usually  having  been  noticed  for  several 
years,  or  hemorrhages  having  occurred  over  this  period;  and  its  dark 
color,  as  seen  with  the  laryngoscope.  The  lack  of  surrounding  indura- 
tion or  ulceration  serves  to  distinguish  it  from  a  malignant  growth. 
Owing  to  its  vascularity,  it  is  not  practicable  to  obtain  a  section  for 
microscopical  examination.  In  examining  tumors  and  cysts  situated 
along  the  line  of  the  thyroglossal  tract,  the  situation  of  the  thyroid 
gland  should  always  be  carefully  palpated  to  determine  the  presence  of 
the  normal  gland. 

Cases  have  been  described  in  which  the  lingual  tumor  was  the  only 
thyroid  substance  present,  and  its  removal  was  followed  by  myxedema. 

Perihyoid  Thyroid  Tumors  and  Cysts. — Besides  the  thyroid 
gland  substance  that  occurs  along  the  tract  within  the  substance  of  the 
tongue,  aberrant  thyroids  have  been  found  in  and  about  the  hyoid  bone. 
Streckeisen  described  these  aberrant  thyroid  masses,  and  Spalteholz 
refers  to  these  as  glandulae  thyroideae  accesoriae.  Treves  is  inclined 
to  hold  them  responsible  for  certain  deep  carcinoma  developing  in  the 
neighborhood  of  the  hyoid  bone. 

Thyroid  tumors  and  cysts  occurring  above  the  hyoid  tend  to  project 
externally  between  the  chin  and  hyoid  bone,  or  upward  and  backward, 
pushing  the  base  of  the  tongue  before  them,  or  they  may  separate  the 
muscular  layers  in  the  midline  and  project  under  the  mucous  membrane 
of  the  dorsum  of  the  tongue.  They  can  usually  be  observed  and  felt 
from  without,  and  if  deeply  situated,  can  be  felt  by  bimanual  palpation. 
They  may  be  cystic  or  solid  and  may  cause  symptoms  varying  from'  slight 
difificulty  of  speech  to  suffocation.  If  they  come  to  lie  immediately  be- 
neath the  mucous  membrane  of  the  dorsum  of  the  tongue,  they  may 
cause  hemorrhages,  similar  to  those  that  occur  with  thyroid  tumors 
originating  near  the  foramen  cecum.  Cysts  and  tumors  originating  in 
front  of  the  mylohyoid  are  apt  to  become  pendulous  when  they  attain 
considerable  size. 

Those  tumors  or  cysts  that  lie  below  the  hyoid  are  usually  attached 
to  its  lower  border  or  posterior  surface.  Cysts  often  extend  up  between 
the  bone  and  the  thyrohyoid  ligament.  The  latter  ligament  is  attached 
near  the  superior  border  of  the  bone,  with  a  rather  inaccessible  space 


546 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


between  the  membrane  and  the  posterior  surface  of  the  bone.  Cysts 
attached  in  this  space  have  often  been  difficult  to  cure.  They  are  liable 
to  become  infected  from  such  ill-advised  treatment  as  puncture  and 
injection,  and  sinuses  remain  that  lead  up  behind  the  bone.  These 
sinuses  intermittently  discharge  a  glary  fluid,  or,  becoming  obstructed, 
bulge  with  the  contained  fluid.  When  the  cavity  is  infected,  the  accumu- 
lation is  accompanied  by  acute  inflammatory  symptoms.  Unless  all  of  the 
epithelium  is  removed,  recurrence  will  take  place.  These  cysts  and  tu- 
mors always  contain  at  least  remnants  of  thyroid  tissue  or  ciliated  epithe- 
lium, which  precludes  their  origin  from  a  thyrohyoid  bursa  (Fig.  407). 
Treatment  of  Thyroglossal  Tract  Tumors  and  Cysts. — Tumors 
situated  near  the  foramen  cecum,  which  have  persisted  for  some  time 
and  are  not  increasing  in  size,  and  which  cause  neither  subjective  symp- 
toms nor  hemorrhage,  have  been  considered  to  require  no  treatment, 


Fig.  405.  Scars  resulting  from  repeated  inflammation,  and  incomplete  operations 
on  a  thyroglossal  duct  fistula. 

as  they  have  never  been  known  to  become  malignant.  When  treatment 
becomes  necessary,  it  should  be  excision.  Owing  to  the  vascularity  and 
inaccessibility  of  the  growths,  the  galvano-cautery  or  hot  snare  is  al- 
most universally  recommended  for  the  removal  of  all  but  very  large 
growths ;  and  when  used,  the  cautery  should  be  at  a  dull  heat  to  prevent 
bleeding. 

Partial  excision  of  a  lingual  or  suprahyoid  tumor  might  be  done, 
if  the'  size  of  the  tumor  causes  annoyance  and  no  normal  thyroid  tumor 
can  be  felt.  If,  after  excision  of  a  lingual  or  suprahyoid  goiter, 
myxedema  should  develop,  thyroid  extract  would  have  to  be  continued 
indefinitely.  The  smaller  growths  may  be  reached  by  opening  the 
mouth  with  a  gag,  drawing  the  tongue  forward,  and  working  with  a 
laryngoscopical  mirror.  The  hot  snare  can  remove  only  the  projecting 
part  of  the  mass,  but  this  has  been  followed  by  satisfactory  results  in 
two  cases,  cited  by  Butlin.     There  was  for  a  time  an  apparent  re- 


TUMORS  OF  THE  TONGUE. 


547 


currence  after  this  method  of  treatment,  which  later  disappeared. 
When  the  growth  is  too  large  to  be  removed  in  this  way,  access  to  the 
pharyngeal  surface  of  the  tongue  may  be  had  by  a  high  lateral  pharyn- 
gotomy.  It  is  our  preference,  for  reasons  already  stated,  to  approach 
all  deeply  situated  tumors  of  the  tongue  and  the  floor  by  an  external 
incision,  and  we  believe  that  these  very  vascular  growths  can  be  more 
safely  and  completely  removed  in  this  manner.  (For  technicjue,  see 
under  Removal  of  Dermoid  Cysts,  page  488.)  Perihyoid  tumors  and 
cysts  are  to  be  treated  in  the  same  manner. 

The  treatment  of  tumors,  cysts,  or  sinuses  is  by  excision  through  a 
median  incision,  but  it  is  absolutely  necessary  that  the  retrohyoid,  or 
even  intrahyoid.  part  be  removed.  We  have  seen  a  number  of  cases  of 
sinuses  in  this  region  that  had  been  repeatedly  incompletely  removed,  or 
had  been  cauterized,  but  not  one  of  them  were  permanently  cured  by 


Pig.  406.  The  external  opening  of  a  thyroglossal  fistula  In  a  child  eleven  years 
old.     Removed  completely  without  difficulty,  after  dividing  the  hyoid  bone. 

this  treatment  (Fig.  405).  The  simplest  way  of  reaching  the  retro- 
hyoid attachment  is  by  cutting  the  bone  in  two  or  removing  a  section 
of  the  body.  It  has  not  been  found  that  dividing  the  hyoid  causes  sub- 
sequent trouble,  if  the  halves  are  sutured  by  their  facial  coverings  or  if 
a  section  of  the  body  is  removed  (Fig.  406).  If  a  section  is  removed 
from  the  body,  sufficient  bone  must  be  retained  to  preserve  at  least  part 
of  the  attachment  of  the  geniohyoid  and  geniohyoglossi  muscles  (Fig. 
407). 

PAPILLOMATA,  WARTS. 

These  are  local  epithelial  proliferations  that  grow  toward  the  surface 
and  remain  superficial  to  the  basement  membrane.  This  distinguishes 
them  from  malignant  epithelioma — cancer — in  which  the  multiplying 
cells  break  through  the  basement  membrane  and  invade  the  deeper 
tissues.     They  are  not  uncommon  in  the  mouth,  occurring  upon  the 


548 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


dorsum  of  the  tongue,  although  they  may  grow  on  the  under  surface 
of  the  tongue,  on  the  lips,  or  on  the  inner  surface  of  the  cheeks.  They 
are  usually  single,  but  may  be  multiple.  Butlin  cites  a  case  of  a  boy  in 
St.  Bartholomew's  Hospital,  who  had  a  warty  enlargement  of  all  the 
fungiform  papillae  of  the  tongue.  They  may  occur  at  any  age,  but  are 
of  much  greater  surgical  interest  in  persons  who  have  reached  what  is 
regarded  as  the  cancer  age.  This  is  especially  true  of  warts  that  de- 
velop in  a  patch  of  leucoplakia  or  chronic  superficial  glossitis,  as,  ac- 
cording to  Butlin,  these  almost  invariably  become  cancerous,  if  not 
so  from  the  first.     Papillomata  within  the  mouth  resemble  warts  in 


Fig.  407.  The  region  of  the  foramen  cecum  of  the  tongue  and  the  retrohyoid  space 
approached  through  a  transverse  submaxillary  incision  in  the  skin,  and  a  vertical  in- 
cision of  the  mylohyoid  muscle  and  thyroid  membrane,  and  division  of  the  body  of  the 
hyoid  bone.  Such  an  approach  is  useful  with  some  tumors  and  cysts  of  the  thyroglossal 
duct. 

Other  parts  of  the  body,  but  on  the  lip,  as  already  mentioned,  they  may 
develop  true  horn.  When  developing  within  a  patch  of  leucoplakia, 
they  at  first  look  like  a  localized  thickening  in  the  patch,  but  later  their 
watery  character  becomes  apparent.  Condylomata  and  mucous  patches 
in  protected  areas — such  as  under  the  tongue — may  resemble  a  soft 
wart,  but  their  recent  growth  and  other  signs  of  syphilis  will  usually 
give  a  hint  as  to  their  character. 

Treatment. — Considering  the  fact  that  these  growths  are  closely 
related  to  cancer  and  within  the  mouth  in  older  persons  are  often  but 
an  early  manifestation  of  cancer,  we  believe  that  there  can  be  no  mis- 


TUMORS  OF  THE  TONGUE.  549 

take  in  the  position  that  they  should  be  removed.  There  are  many  ways 
of  removing  bt  destroying  a  wart,  but  the  most  certain  is  the  removal  of 
its  base  by  a  wedge-shaped  excision;  and  if  followed  by  immediate 
suture,  primary  union  will  occur.  In  this  way  the  complete  removal  is 
assured,  and  the  postoperative  discomfort  is  reduced  to  a  minimum,  as 
is  the  amount  of  resulting  scar  tissue;  and  the  growth  is  preserved  for 
examination.  Ordinarily  the  incision  may  be  carried  within  two  milli- 
meters of  the  base  of  the  wart.  But  those  that  are  at  all  indurated  at 
the  base,  are  ulcerated,  or  those  that  occur  in  a  patch  of  leucoplakia  or 
chronic  inflammation  or  induration  should  be  regarded  as  probably 
cancerous;  and  the  line  of  incision  had  better  be  1  centimeter  from 
the  base,  and  the  wedge  of  tissue  removed  correspondingly  deep.  After 
removal,  the  growth  should  be  examined  microscopically.  We  have 
been  struck  with  the  large  proportion  of  inactive,  apparently  innocent 
papillomata  that  in  routine  examination  showed  histological  character- 
istics of  carcinoma. 

SARCOMA. 

This  is  one  of  the  rarest  of  tumors  of  the  tongue.  But  a  few  have 
been  reported  in  literature,  and  of  a  number  of  these,  description  of  the 
microscopical  appearance  and  the  clinical  behavior  have  led  to  a  doubt 
or  a  negation  of  their  sarcomatous  nature.  Of  the  true  sarcomata,  most 
have  been  of  small,  round  cell  type,  some  with  considerable  fibrous 
tissue.  Some  of  these  small,  round  cell  growths  have  been  supposed 
to  be  lymphosarcomata  developing  from  lymphangiomata.  There  is 
nothing  characteristic  about  their  location  or  mode  of  origin,  and  among 
those  reported,  several  have  appeared  early,  but  grown  intermittently, 
remaining  stationary  for  years,  only  to  terminate  in  extreme  malig- 
nancy. Von  Bergmann  states  that  even  in  the  earlier  stages  they  are 
always  very  painful.  This  does  not  correspond  with  sarcomata  in  other 
regions,  where  they  are  usually  not  painful.  Some  ulcerate  early,  while 
others  reach  considerable  size  without  involvement  of  the  mucous  mem- 
brane. When  ulceration  is  excessive,  the  growth  might  be  taken  for 
gumma  or  carcinoma.  Some  have  caused  enlargement  of  the  regional 
lymph  nodes,  while  others  have  not. 

In  some  instances,  the  lymphatic  enlargement  has  been  purely  from 
septic  irritation ;  while,  in  a  case  reported  by  Bloodgood  and  another  by 
Butlin,  an  enlargement  of  the  submaxillary  gland,  which  subsided  after 
the  removal  of  the  lingual  tumor,  was  due  to  pressure  on  the  duct. 

Those  sarcomata  that  cause  a  real  involvement  of  the  lymph  nodes 
are  probably  of  the  lymphatic  type.  The  malignancy  of  the  growths 
varies  excessively,  and  their  histological  character  seems  to  furnish 
little  light  on  the  prognosis.    Rapidly  growing,  small,  round  cell  sarco- 


550  SURGERY  OF  THE  MOUTH  AND  JAWS. 

mata  have  been  removed  from  the  tongue,  with  no  return  for  years 
afterward;  yet,  in  as  many  reported  cases,  the  growth  has  returned 
repeatedly,  both  locally  and  in  the  lymph  nodes,  after  short  periods,  in 
spite  of  extensive  operations. 

The  diagnosis  of  sarcoma,  in  order  to  be  of  use  to  the  patient,  must 
be  made  microscopically ;  the  specimen  removed  for  this  purpose  should 
include  the  edge  of  the  growth  and  a  portion  of  the  surrounding  tissue. 
Between  hypertrophy  of  the  lingual  tonsil  and  lymphosarcoma  the  mi- 
croscope may  fail  to  distinguish.  Tumors  growing  in  the  neighborhood 
of  the  foramen  cecum  should  not  be  incised  with  impunity,  as  the 
aberrant  thyroid  growths  are  extremely  vascular  and  might  give  rise 
to  troublesome  hemorrhage.  After  removing  a  piece  of  any  growth 
for  microscopical  examination,  the  raw  surface  should  be  immediately 
cauterized  to  control  hemorrhage  and  prevent  distant  transplantation. 

Treatment. — The  diagnosis  having  been  established,  the  treat- 
ment is,  of  course,  removal,  with  a  wide  sweep  into  the  healthy  tissue. 
If  the  lymph  nodes  are  enlarged,  these  should  be  removed  if,  upon 
microscopical  examination,  the  enlargement  proves  to  be  due  to  infec- 
tion with  the  growth.  It  is  questionable  if  more  extensive  operating 
is  indicated  than  is  necessary  to  remove  the  evident  growth  with  a  fair 
margin  of  the  healthy  tissue,  for  some  sarcomata  have  remained  cured 
for  years  after  being  removed  with  a  very  meager  amount  of  healthy 
tissue,  while  others  have  returned  after  repeated  extensive  operations. 
The  result  depends  so  much  upon  the  degree  of  malignancy  of  the  tumor 
that,  provided  the  incision  is  carried  beyond  the  apparent  limits  of  the 
growth,  the  character  of  the  operation  seems  to  have  little  influence 
on  the  outcome.  That  persistent  and  repeated  removal  of  the  evident 
growth  may  be  followed  by  a  good  result  is  demonstrated  by  one 
presented  by  Mikulicz  in  his  atlas.  The  anterior  part  of  the  tongue 
was  amputated  for  a  spindle  cell  sarcoma  that  occupied  both  sides  of 
the  anterior  third  and  which  had  been  noticed  for  three  months.  Six 
months  later,  an  operation  was  done  for  a  secondary  growth  in  the 
lymph  nodes,  which  was  followed  by  a  second  operation  on  the  lym- 
phatics six  months  after  the  first  gland  operation.  Three  years  after 
the  first  operation,  there  was  no  return,  although  there  had  been  an 
ulceration  in  the  scar,  which  healed  on  the  removal  of  some  carious 
teeth. 

As  with  sarcomata  of  the  jaw,  we  believe  that  Coley's  toxins  should 
be  persisted  in  for  several  months  after  each  operation. 


CHAPTER  XXXVIII. 

CANCER  OF  THE  TONGUE. 

It  is  generally  accepted  that  this  is  always  a  squamous  epithelioma 
and,  unless  an  extension  from  the  floor  of  the  mouth,  is  never  of  the 
granular  type.  According  to  von  Bergmann,  Steiner  reports  one  that 
is  apparently  an  exception.  We  observed  one  in  the  author's  service 
at  the  O'Fallon  Dispensary  that  had  apparently  originated  deeply  in  the 
tongue,  the  tumor  occupying  most  of  one  half  of  the  body,  fixing  it  to 
the  floor,  but  not  involving  the  mucous  membrane  of  the  dorsum. 
There  was  no  ulceration  until  after  a  section  had  been  removed  for 
microscopical  examination.  Dr.  Tiedemann,  pathologist  at  the  Wash- 
ington University  Medical  School,  reported  that  it  was  a  columnar 
epithelioma.  It  is  possible  that  this  originated  in  the  sublingual  gland, 
but  the  floor  of  the  mouth  was  little  involved  compared  with  the  tongue. 
It  had  persisted  for  three  months,  and  at  the  time  pain  and  distressing 
salivation  were  well  marked. 

POSITION. 

Cancer  may  occur  on  any  part  of  the  tongue,  but  the  under  surface, 
tip,  and  root  are  much  more  often  exempt  than  are  the  dorsum  and 
borders  of  the  body.  This  corresponds  with  the  more  common  sites  of 
the  supposedly  precancerous  conditions,  including  trauma  of  the  borders 
from  rough  teeth,  and  at  this  site  the  dorsum  is  constantly  covered  with 
fur,  which  consists  mostly  of  bacteria  clinging  to  the  papillae. 

The  age  at  which  carcinoma  most  commonly  develops  is  between 
forty  and  sixty  years,  but  it  is  probable  that  the  predisposition  increases 
with  age — the  falling  off  in  frequency  after  sixty  or  sixty-five  being 
due  to  the  fact  that  there  are  fewer  people  of  the  more  advanced  ages, 
not  that  they  are  less  susceptible  to  the  disease.  As  with  carcinoma  of 
the  lip,  the  disease  occasionally  occurs  in  young  persons,  even  children, 
but  is  then  always  extremely  malignant. 

ETIOLOGY  AND  PREDISPOSITION. 

A  discussion  of  the  specific  cause  of  cancer  would  be  out  of  place 
here;  although  it  is  possible  that  the  question  may  be  settled  before 
this  book  is  published,  at  present,   and    for  years   past,   more   study 

551 


552  SURGERY  OF  THE  MOUTH  AND  JAWS. 

has  been  expended  upon  it  than  any  other  one  problem  in  pathology, 
and  it  is  today  apparently  little  nearer  actual  solution.  The  two  main 
theories  are:  (1)  that  the  uncontrolled  growth  of  the  epithelial  cells 
is  due  to  some  fault  essential  to  the  tissues  or  acquired  through  me- 
chanical irritation;  (2)  that  the  wild,  ungoverned  epithelial  multipli- 
cation and  invasion  is  due  to  the  irritation  of  some  specific  fungus  or 
other  organism.  If  one  were  to  review  but  a  fraction  of  the  evidence 
that  is  advanced  by  the  exponents  of  either  theory,  he  would  for  the 
time  be  apt  to  feel  that  there  could  be  room  for  no  other  conclusion. 

The  most  common  predisposing  factor  is  age,  and  with  cancer  of 
the  tongue  sex  has  at  least  an  indirect  bearing.  As  stated  before,  85 
per  cent  of  the  cases  occur  in  men.  The  common  explanation  for  this 
is  that  men's  mouths  are  more  frequently  exposed  to  the  irritants  that 
predispose  to  cancer — tobacco,  strong  drink,  and  syphilis.  But  that 
this  is  the  only  cause  is  not  proved.  Of  certain  local  factors  that  pre- 
dispose to  cancer  we  have  considerable  knowledge ;  for  its  accuracy  and 
for  an  appreciation  of  the  importance  of  the  factors,  we  are  indebted 
chiefly  to  Butlin.  "  These  have  been  mentioned  in  previous  chapters  and 
consist  of  changes  in  the  epithelium,  that  can  be  included  under  chronic 
irritations,  inflammations,  and  leucoplakia;  also  deep  scars  and  trau- 
matic ulcers.  (The  latter  are  the  "Dekubitalgeschwiir"  of  the  Ger- 
mans.) Not  by  any  means  that  all  of  these  lesions  are  always  or  even 
commonly  followed  by  cancer,  but  possibly  75  per  cent  of  all  carcinomata 
of  the  tongue  have  been  associated  with  some  one  of  them. 

Of  the  scars  that  may  form  the  starting  point  of  malignant  epi- 
thelial prolifieration,  Butlin  calls  especial  attention  to  those  resulting 
from  the  use  of  strong  caustics  and  the  cautery,  and  throughout  his 
writing  continually  warns  against  their  use  in  those  who  have  reached 
the  cancer  age.  Cancer  following  a  scar  may  be  long  in  showing  itself. 
Among  sixteen  such  cases,  in  various  parts  of  the  body,  gathered  by 
Cheatle,  the  disease  appeared  between  five  and  thirty-five  years  after 
the  injury. 

Of  the  mechanical  causes,  the  most  frequent  is  the  irritation  due  to 
sharp  and  jagged  teeth.  Occasionally  carcinoma  may  develop  in  some 
trivial  acute  injury.  Cancer  of  the  tongue  has  apparently  been  caused 
by  metastasis  from  some  distal  site.  Butlin  cites  one  such  case.  By 
far  the  most  common  local  antecedent  of  cancer  of  the  tongue  is  a 
chronic  superficial  glossitis  or  a  leucoplakia.  According  to  von  Berg- 
mann,  in  a  series  of  159  cases,  over  50  percent  were  preceded  by  distinct 
leucoplakia  or  chronic  white  patches.  A  fair  percentage  of  carcinoma, 
probably  25  per  cent,  develops  independently  of  any  recognizable  pre- 
cancerous lesion. 


CANCER  OF  THE  TONGUE.  553 

EARLY    DIAGNOSIS  —  RESPONSIBILITY     OF    MEDICAL 

PRACTITIONERS  AND  DENTISTS  IN  REGARD 

TO  THE  RECOGNITION  OF  THE  EARLY 

MANIFESTATIONS  OF  CANCER. 

Considering,  on  the  one  hand,  its  invariable  outcome,  unless  suc- 
cessfully operated  upon,  the  sufferings  of  the  victim,  and  the  improba- 
bility of  successful  treatment  in  the  advanced  stages ;  on  the  other  hand, 
the  success,  or  long  periods  of  immunity,  that  may  follow  compar- 
atively simple  early  operation,  the  importance  of  very  early  diagnosis 
cannot  be  overestimated.  It,  together  v^rith  the  conditions  which  so 
frequently  antedate  its  clinical  development,  should  be  the  subject  of 
study  not  only  by  surgeons  but  by  all  practitioners  who  have  occasion 
to  examine  the  buccal  cavity.  As  far  as  we  know,  nowhere  else — un- 
less it  be  the  stomach — are  the  majority  of  clinical  carcinomata  preceded 
by  recognizable  lesions,  and  nowhere  can  these  precancerous  or  early 
cancerous  conditions  be  observed  as  well  as  in  the  mouth,  where  they 
often  persist  for  years  before  becoming  malignant  or  show  malignancy, 
and  where  developing  abnormalities  are  so  quickly  recognized  by  the 
patient.  If  there  is  sound  basis  for  hope  that  a  routine  periodic  exam- 
ination of  women  who  have  reached  the  cancer  age  will  very  materially 
reduce  the  death  rate  from  cervical  cancer,  much  more  could  reasonably 
be  hoped  in  reference  to  the  tongue  and  mouth,  if  medical  practitioners 
and  dentists  universally  recognized  the  importance  of  all  chronic  lesions 
and  treated  and  instructed  their  patients  accordingly.  The  onus  of 
this  responsibility  rests  chiefly  upon  the  dentist.  There  are  few  persons 
in  this  country  who  do  not  consult  a  dentist,  not  only  once,  but  re- 
peatedly. It  is  during  what  is  termed  the  cancer  age  that  the  teeth 
are  disintegrating  or  artificial  teeth  are  worn.  Until  the  much  desired 
cancer  specific  is  discovered,  it  is  mainly  to  the  educated  dentist, 
grounded  in  general  oral  pathology,  who  makes  a  complete,  though 
quick,  survey  of  the  whole  mouth,  that  the  medical  profession  and  the 
public  must  look  to  reduce  the  now  increasing  death  rate  from  cancer 
of  the  tongue. 

In  1909,  Mr.  Butlin  stated  that  he  had  operated  upon  only  a  little 
more  than  two  hundred  cases  of  cancer  of  the  tongue  in  twenty-five 
years,  and  he  is  recognized  as  the  foremost  man  in  connection  with  the 
study  and  treatment  of  this  disease.  He  states  that  Whitehead  has 
probably  operated  upon  the  same  number,  that  Kocher  has  operated  on 
possibly  one  hundred  and  forty,  and  few  other  surgeons  have  operated 
upon  a  hundred  cases.  Warren  states  that  but  63  cases  were  operated 
on  in  the  Massachusetts  General  Hospital  between  1892  and  1906,  fif- 
teen years.  Struck  with  the  paucity  of  cases  that  come  to  operation, 
Butlin  wrote  to  the  General  Registry  Ofiice  of  England  requesting 


554  SURGERY  OF  THE  MOUTH  AND  JAWS. 

statistics  on  the  occurrence  of  cancer  of  the  tongue.  Dr.  Tatham  gave 
the  death  rate  from  the  disease  in  England  for  several  years,  which 
showed  an  average  of  seven  hundred  and  fifty  deaths  a  year.  Butlin 
estimates  that  there  may  be  seventy  sucessfully  operated  cases  a  year, 
which  would  bring  the  number  of  cases  up  to  eight  hundred  and  twenty 
annually.  This  can  only  mean  that  the  vast  majority  of  cases  are  al- 
lowed to  go  unoperated,  or  are  operated  on  at  a  time  when  they  have 
become  incurable.  Yet,  unlike  the  disease  in  the  stomach,  breast  or 
uterus,  the  patient  in  almost  every  instance  must  have  known  that 
he  had  something  wrong  with  his  tongue,  either  from  the  time  when 
the  cancer  first  appeared  or  often  for  years  beforehand ;  and  in  most 
cases  either  the  early  cancer  or  the  condition  that  led  to  it  must  have 
been  observed  by  some  medical  practitioner  or  dentist. 

Our  one  present  hope  for  cure  of  cancer  of  the  tongue  is  early 
diagnosis  and  operation.  This  is  to  be  more  appreciated  when  we 
consider  not  only  the  late  but  also  the  immediate  results  of  operations 
on  early  and  later  cases.  The  operative  death  rate  of  the  earlier  cases 
is  something  between  3  and  5  per  cent,  while  the  cures  (three-year  limit) 
may  on  Butlin's  statistics  be  estimated  at  something  between  50  and  60 
per  cent.  With  the  later  operations,  those  in  which  the  disease  may 
still  be  considered  as  possibly  curable,  the  immediate  death  rate  jumps 
to  between  20  and  30  per  cent,  and  the  cures  may  be  placed  well  below 
10  per  cent.  Warren  places  his  cures,  in  cases  in  which  the  disease  was 
confined  to  the  tongue  and  floor  of  the  mouth,  at  31  per  cent,  but  when 
it  has  spread  to  other  structures,  at  3.4  per  cent.  Of  172  cases  of  can- 
cer of  the  tongue  and  mouth  in  the  Massachusetts  General  Hospital,  50, 
or  29  per  cent,  were  considered  inoperable  when  they  entered. 

EARLY  TYPES  OF  CANCER. 

Even  more  important  than  knowledge  of  the  conditions  that  may 
predispose  to  cancer  is  that  of  the  early  appearance  of  the  disease  itself. 
These  unfortunately  are  various  and  not  always  easily  recognized. 
According  to  Butlin,  these  may  be  in  the  form  of  a  wart,  fissure,  super- 
ficial abrasion,  pimple,  superficial  tubercle,  or  deep  submucous  nodule — 
the  last  being  the  least  frequent  form  of  a  starting  carcinoma.  He 
explained  these  varied  appearances  in  the  initial  stage,  not  by  the  suppo- 
sition that  various  sorts  of  lesions  of  independent  origin  and  character 
are  cancer  from  the  first,  but  that  they  may  become  infected  with  carci- 
noma. He  mentions  five  conditions,  which  he  considers  the  most 
typical  and  most  frequent  forms  of  early  cancer  of  the  tongue : 

"(1)  A  little  plaque-like,  hard  sore,  smooth  and  polished,  but  neither 
ulcerated  nor  excoriated.  (2)  The  transformation  or  replacement  of 
a  simple  ulcer  by  a  cancerous  ulcer,  which  only  differs  from  the  simple 


CANCER  OF  THE  TONGUE.  555 

ulcer  by  feeling  a  very  little  stiff er  and  a  very  little  firmer.  (3)  The 
transformation  of  an  entire  plaque  of  leucoplakia  into  a  plaque  of 
cancer.  The  difference  is  marked  by  very  slight  thickening,  a  denser 
white,  and  furrowing  and  Assuring  in  various  directions,  but  without 
excoriation  or  ulceration.  (4)  The  transformation  of  one  small  area 
of  a  leucoplakia  tongue  into  cancer,  only  marked  at  first  by  very  slight 
and  superficial  hardening.  (5)  A  white,  warty  growth  or  compound 
wart,  neither  broken  nor  ulcerated,  and  feeling  at  first  as  if  it  were 
fixed  to  the  mucous  membrane  and  quite  superficial." 

He  also  states  that  there  are  other  conditions  in  which  cancer  of  the 
tongue  may  begin,  but  that  these  five  are  the  most  frequent.  Twelve 
colored  plates  illustrating  these  conditions  have  been  published  by  But- 
lin,  which  are  worthy  of  careful  study.  In  his  early  writings,  he 
classified  certain  papules,  warts,  and  slightly  indurated  ulcers  that  were 
always  followed  by  the  development  of  clinically  typical  carcinoma  as 
"precancerous."  Later,  based  upon  the  discovery  that  indurated  ulcers 
and  papules  and  warts,  developing  in  a  patch  of  chronic  superficial 
glossitis  or  leucoplakia,  were  from  their  beginning  microscopically 
typical  carcinomata,  he  was  led  to  this  statement:  "I  am  now  won- 
dering whether  there  are  really  any  conditions  perceptible  to  touch  or 
sight  which  are  precancerous  in  the  sense  which  I  have  been  accus- 
tomed to  employ  them."  That  is  to  say,  he  formerly  thought  that  warts 
and  papules  turned  from  non-malignant  to  malignant  lesions.  From  a 
rather  careful  study  of  his  writings,  we  believe  that  this  implied  elimi- 
nation of  the  term  precancerous  refers  only  to  epithelial  growths  and 
the  ulcers  that  follow  them,  which  is  in  accord  with  the  views  of  many 
pathologists;  that  a  truly  benign  epithelial  wart  or  papilloma  never 
undergoes  malignant  degeneration. 

EARLY  CLINICAL  CHARACTERISTICS. 

When  the  new  cancer  has  persisted  for  some  indefinite  time,  there 
are  certain  early  clinical  characteristics,  the  presence  of  some  of  which 
may  make  a  diagnosis  possible. 

Chronicity. — The  first  of  these  is  that  the  disease,  having  once 
started,  probably  rarely  recedes.  An  apparent  contradiction  to  this 
statement  is  that,  in  the  history  of  certain  superficial  inflammations,  an 
ulcer  may  appear  and  disappear  spontaneously,  to  be  later  followed  by 
an  ulcer  that  is  indurated  and  proves  to  be  cancer.  According  to  our 
present  idea,  the  most  likely  explanation  of  this  is  that  the  first  ulcer 
was  of  a  simple  nature,  and  that  its  successor  was  an  ulceration  in  a 
superficial  cancerous  induration  that  developed  at  the  site  of  the  first. 
In  the  lip  a  true  glandular  cancer,  the  rodent  ulcer,  may  recede  and  even 


556  SURGERY  OF  THE  MOUTH  AND  JAWS. 

scar  over,  only  to  break  down  again,  but  this  is  apparently  a  rare  occur- 
rence with  squamous  epitheliomata.  In  the  earlier  stages  its  progress  is 
not  rapid,  and  it  may  appear  for  months  as  an  indolent  sore.  In  this 
stage,  the  only  suspicious  thing  about  it  is  that,  after  removing  the 
source  of  irritation,  it  does  not  yield  to  such  simple  remedies  as  appear 
to  be  indicated. 

Continuous  Growth. — The  next  thing  noticed  about  carcinoma 
is  that  it  not  only  does  not  recede,  but  is  progressive.  This  extension 
is  occasionally  shown  in  the  form  of  external  growth,  but  much  more 
commonly  by  induration  and  ulceration.  The  base  of  a  wart,  the  edge 
of  a  fissure,  or  the  surface  of  an  abrasion  becomes  hard,  while  a  deep 
nodule  becomes  large.  Any  slowly  extending  induration  in  the  tongue 
of  a  man,  over  forty  years  of  age,  not  due  to  some  evident  cause,  should 
always  excite  grave  suspicion.  Even  when  there  is  an  apparent  cause 
for  the  induration,  vigilance  should  not  be  relaxed  until  it  has  entirely 
subsided,  or  until  sufficient  time  has  elapsed  without  farther  extension 
to  preclude  its  being  cancer.  An  induration  could  be  partly  due  to  a 
developing  carcinoma,  but  mostly  to  an  inflammation,  and  as  the  latter 
subsides,  the  decrease  in  the  extent  of  the  induration  might  be  mis- 
leading. 

Induration. — The  induration  is  often  of  a  hardness  that  is  diffi- 
cult to  mistake  for  anything  else,  although  when  surrounding  an  ulcer 
it  may  for  a  time  be  so  limited  as  to  escape  notice.  It  is  best  detected 
by  pinching  up  the  suspected  tissue  between  the  finger  and  thumb. 

Ulceration. — Another  symptomi  of  carcinoma,  which  may  be  the 
earliest  objective  sign,  is  ulceration.  This  is  always  surrounded  by  a 
wall  of  new  growth  in  which  the  ulceration  occurs,  but  it  may  be  so 
limited  in  extent  as  to  be  not  very  evident.  In  other  words,  the  growth 
may  be  continuously  destroyed  almost  as  rapidly  as  it  forms,  leaving 
only  a  thin  layer  of  compact  cancer  substance  between  the  floor  of  the 
ulcer  and  the  apparently  normal  tissue.  The  ulceration  may  appear 
over  a  large  surface  before  any  induration  can  be  felt.  This  may  occur 
over  an  area  of  chronic  superficial  glossitis  that  has  taken  on  malig- 
nancy.    (For  further  characteristics  of  ulceration,  see  page  558.) 

Pain. — The  fourth  symptom  in  the  order  of  diagnostic  importance 
in  pain.  (For  the  characteristics  of  this  pain,  see  page  558.)  It  is 
possible  that  pain  is  not  infrequently  a  very  early  symptom  and  may  be 
the  first  to  attract  the  patient's  attention.  It  may  even  occur  months 
before  there  are  recognizable  objective  signs.  A  man  from  the  O'Fal- 
lon  Dispensary,  neurological  service,  was  referred  to  the  author  as  a 
case  of  tic  douloureux.  Although  the  location  of  the  pain  deep  in  the 
ear  was  not  characteristic  of  major  tic,  still,  for  want  of  anything 
definite  except  the  pain,  the  third  division  of  the  fifth  nerve  was  injected, 


CANCER  OF  THE  TONGUE.  557 

giving  some  relief.  The  man  was  asked  to  return  for  observation,  but 
was  lost  sight  of.  Six  months  later  he  returned,  complaining  of  the 
pain  and  of  hemorrhage  from  the  mouth.  Another  examination  re- 
vealed one  of  those  deep-fissured  carcinomata,  far  back  under  the 
tongue,  which  are  almost  peculiar  to  this  site.  That  there  might  have 
been  some  slight  objective  sign  of  the  cancer  at  the  first  examination 
we  cannot  deny;  but  if  there,  it  was  overlooked  by  the  chiefs  and  as- 
sistants of  two  out-clinics  and  of  one  ward,  and  at  the  time  of  recog- 
nition was  very  difficult  to  see  with  the  tongue  elevated.  In  a  series  of 
seven  early  carcinomata,  reported  by  Butlin,  we  notice  that  in  one  pain 
had  been  present  for  several  months  "in  the  place  where  the  ulcer  was," 
and  in  another  pain  preceded  the  formation  of  a  plaque  by  eight  months. 

Microscopical  Appearance. — When  one  or  several  of  the  above 
symptoms  have  aroused  the  suspicion  that  a  growth  is  cancerous,  the 
final  test  is  made  by  a  microscopical  examination  of  either  the  whole 
specimen  or  of  a  section  removed  for  that  purpose,  which  should  include 
a  portion  of  the  healthy  bordering  tissue.  This  examination  should 
never  be  omitted  when  a  doubt  is  raised,  but  to  be  of  use,  it  must  be 
made  by  one  specially  trained  for  the  work  (see  page  556). 

Salivation  and  enlargement  of  the  lymphatic  nodes,  though  constant 
symptoms  of  the  older  growths,  are  rarely  related  to  the  earlier  stages. 
Occasionally  the  lymph  nodes  will  become  enlarged,  apparently  simul- 
taneously with  the  discovery  of  the  primary  growth,  or  the  lymphatic 
enlargement  may  be  the  first  symptom  that  leads  to  the  finding  of  the 
primary  growth.  It  is  probable  that  even  in  these  cases  the  original 
tumor  for  some  time  presented  symptoms  that,  though  unobserved,  were 
nevertheless  characteristic. 

CLINICAL  STAGES   OF  CARCINOMA   OF  THE  TONGUE. 

A  cancer  is  a  true  cancer  from  the  time  the  first  cell  takes  on  ma- 
lignancy and  throws  off  the  restraint  that  limits  normal  reproduction 
to  above  the  basement  membrane.  Therefore  it  is  not  in  exact  accord 
with  the  pathology  to  speak  of  an  immature  or  a  fully  developed  cancer, 
but  it  is  convenient  in  presenting  the  subject  to  divide  the  stages  of  its 
growth  into  three  periods.  The  first  of  these  stages  has  just  been  dis- 
cussed. The  second  period  might  be  considered  to  start  at  the  time 
when  the  objective  symptoms  render  the  diagnosis  rather  obvious.  A 
third  and  final  stage  is  that  during  which  it  is  no  longer  curable  by 
operation.  It  is  impossible  in  any  given  case  to  say  just  at  what  time 
the  growth  merges  from  the  second  to  the  third  stage — that  is,  at  what 
moment  a  growth  becomes  inoperable — but  when  well  advanced  the 
third  stage  is  easily  recognizable. 


558  SURGERY  OF  THE  MOUTH  AND  JAWS. 

MID-PERIOD  OF  CARCINOMA  OF  THE  TONGUE. 

At  the  beginning-  of  this  period  some  one  or  more  symptoms  will 
assume  a  more  typical  form.  Later,  owing  to  the  progressive  growth, 
ulceration  and  subsequent  enlargement  of  the  lymph  nodes,  pain, 
hemorrhage,  and  distressing  salivation  are  commonly  added,  while  the 
peculiar  general  depression  or  intoxication,  known  as  cachexia,  is  a 
thing  that  no  cancer  patient  escapes  unless  the  growth  is  removed 
before  this  has  had  time  to  develop.  Besides  these,  a  profuse  discharge 
and  a  sickening  odor  are  almost  certain  to  hold  a  prominent  place  in 
the  later  picture.  As  stated  before,  active  growth,  having  once  started, 
is  progressive — in  some  cases  slowly,  in  others  very  rapidly — but  it 
never  ceases. 

Growth. — Sometimes  growth  continues  in  the  form  of  an  ex- 
ternal tumor  that  may  become  very  evident,  even  to  protruding  from  the 
mouth ;  but  this  is  very  rare,  and  the  later  extension  is  usually  only  in 
the  form  of  an  induration  that  can  be  felt  better  than  seen.  Often  this 
induration  is  almost  as  hard  as  cartilage,  but  it  may  be  relatively  soft. 
In  a  form  of  cancer  that  is  very  rare  in  the  tongue,  the  scirrhus,  growth 
may  be  accompanied  by  an  interstitial  scar  contraction  that  may  lessen 
the  normal  size  of  the  tongue  without  much  ulceration  being  present. 

Ulceration. — This  constant  symptom  of  lingual  carcinoma,  due 
to  a  superficial  disintegration  of  the  ill-nourished  cancer  tissue,  may 
appear  before  the  induration  is  evident  or  not  until  the  tumor  has 
attained  some  size,  but  it  is  usually  a  fairly  early  symptom.  Butlin 
regards  it  as  an  almost  necessary  symptom  and  states  that  though 
the  hard,  dry  surface  of  certain  warty  growths  may  remain  unbroken 
for  some  time,  even  here  ulceration  is  never  delayed  more  than  a  few 
weeks.  In  the  case  referred  to  on  page  551,  we  refused  to  confirm  the 
diagnosis  of  carcinoma  until  it  had  been  demonstrated  by  microscopical 
examination,  because  the  growth  had  been  present  three  months  without 
ulceration.  This  was  in  spite  of  the  fact  that  several  other  typical 
symptoms  were  present,  but  a  columnar  cell  cancer  of  the  tongue  is  a 
surgical  curiosity.  The  ulceration  may  destroy  the  induration  so 
rapidly  as  to  be  the  most  prominent  feature.  It  may  be  on  a  sur- 
face or  deep  in  a  fissure  that  rriakes  but  little  surface  showing.  It 
may  present  a  smooth,  red  surface  that  joins  the  mucous  membrane  in 
a  sharp  outline,  or  it  may  be  covered  with  ragged  sloughs  or  foul 
septic  granulations.  One  prominent  characteristic  of  the  ulceration  of 
carcinoma  on  the  tongue  is  that  its  edges  are  usually  rolled  and  promi- 
nent, seldom  "punched  out,"  and  almost  never  undermined.  This  is  an 
important  point  in  distinguishing  between  a  carcinomatous  ulcer  and 
an  ulcerating  gumma. 

Pain. — Pain  as  a  rule  develops  early  and  is  usually  of  an  intense, 


CANCER  OF  THE  TONGUE.  559 

persistent  character,  sometimes  with  a  pecuHar  tendency  to  radiate  to, 
or  be  most  pronounced  in,  the  top  of  the  head  or  deep  in  the  ear.  Pain 
in  the  ear  is  usually  associated  with  cancer  of  the  edge  or  under  surface 
of,  or  far  back  on,  the  tongue.  Often  the  patient  will  be  conscious  of 
little  or  no  pain  in  the  growth,  but  will  suffer  torment  from  pain  at 
one  of  the  sites  mentioned. 

Hemorrhage  and  Salivation. — These  are  rarely  early  symptoms. 
Pain  may  be  intolerable,  the  salivation  distressing,  and  hemorrhage  of 
very  frequent  occurrence,  the  bleeding  being  often  profuse  but  rarely 
directly  fatal. 

Lymphatic  Infection. — Infection  of  the  regional  lymph  nodes 
occurs  sooner  or  later  in  every  case  of  cancer.  In  certain  flat  ulcers  of 
the  lip,  the  glandular  infection  may  apparently  be  long  delayed ;  but 
with  carcinoma  of  the  tongue,  this  is  not  the  case.  Just  how  early  the 
nodes  may  become  involved  or  how^  long  their  infection  may  be  delayed 
is  not  known.  In  spite  of  the  fact  that  in  a  few  cases  the  development 
of  the  intraoral  growth  and  of  the  glandular  involvement  has  seemed 
to  have  occurred  almost  simultaneous!}^,  it  is  certain  that  for  a  time 
the  growth  must  be  local,  and  it  is  probable  that  it  usually  remains  so 
for  a  period  after  it  has  assumed  an  appearance  that  could  be  recog- 
nized as  at  least  suspicious.  In  younger  persons  the  lymphatic  circu- 
lation is  supposed  to  be  more  active  than  in  the  aged,  and  this  is  one 
explanation  advanced  to  partly  account  for  the  extreme  virulency  of 
carcinoma  in  young  subjects.  It  is  also  believed  that  in  very  old  persons 
the  average  interval  is  longer  than  in  middle  life.  It  is  certain  that  the 
interval  is  not  always  the  same,  even  in  persons  of  similar  ages. 

Butlin  states :  "It  is  probable  that  in  the  most  rapidly  progressive 
cases  the  glands  may  be  affected  within  a  few  weeks  after  the  disease 
within  the  mouth  has  become  actually  carcinomatous.  On  the  other 
hand,  there  is  quite  as  good  reason  to  believe  that  carcinoma  of  the 
tongue  may  exist  for  six,  possibly  even  more,  months  before  the  glands 
are  involved."  It  may  be  possible  that  glandular  infection  occurs  much 
earlier  than  is  supposed.  It  cannot  be  taken  to  mean  that  infection  has 
not  occurred,  because  the  nodes  are  not  palpable  and  because  by  mi- 
croscopical examination  cancer  cells  cannot  be  demonstrated.  It  is 
more  than  probable  that  the  infection  can  be  held  in  check  in  the 
nodes  for  some  considerable  time,  the  cancer  cells  reaching  the  nodes 
either  lying  dormant  or  even  being  destroyed.  In  a  case  reported  by 
Butlin,  he  had  removed  some  small  plaques  that  he  had  under  enforced 
observation  for  three  months,  in  which  microscopical  examination  re- 
vealed a  very  early  form  of  carcinoma.  So  early  was  the  form  of  the 
disease,  that  one  of  the  pathologists  of  the  Cancer  Research  Institute 
was  not  sure  of  its  character,  but  another,  with  Butlin,  was  satisfied 


560  SURGERY  OF  THE  MOUTH  AND  JAWS. 

it  was  carcinoma.  Owing  to  the  unwillingness  of  the  patient,  no  oper- 
ation was  done  on  the  lymphatics,  and  three  and  a  half  years  later, 
the  man  returned  with  a  very  extensive  involvement  of  all  of  the  nodes 
on  that  side  of  the  neck.  The  intraoral  growth  had  not  recurred.  As 
proved  by  this  case  and  by  observations  made  by  many  other  sur- 
geons, the  fact  that  the  infection  in  the  lymph  nodes  may  apparently 
remain  dormant  for  a  long  period  does  not  negate  its  presence,  and 
many  cases  may  have  been  lost  sight  of  before  the  glandular  infec- 
tion could  be  recognized. 

The  body  of  the  tongue  drains  its  lymph  streams  into  the  submental, 
submaxillary  and  superior  deep  cervical,  and  infrahyoid  nodes.  There 
is  one  lymph  duct  that  drains  the  area  near  the  frenum,  which  passes 
directly  to  a  node  that  lies  near  the  lower  end  of  the  anterior  belly  of 
the  omohyoid  muscle.  Some  of  the  lymph  streams  from  the  dorsum 
run  through  one  or  two  small  nodes  situated  between  the  geniohyo- 
glossi  muscles,  while  other  similar  nodes  have  been  described  in  relation 
to  the  upper  surface  of  the  mylohyoid  muscle. 

The  root  of  the  tongue,  that  part  situated  behind  the  circumvallate 
papillae,  is  derived  from  the  same  structures  that  form  the  pharynx, 
and  its  lymph  streams  drain  directly  into  the  upper  deep  cervical  nodes 
of  the  corresponding  side  through  a  duct  that  pierces  the  wall  of  the 
pharynx  behind  the  tonsil.  There  is  little  communication  between  the 
two  halves  of  the  tongue  anteriorly,  but  in  the  root  the  anastomosis  is 
free. 

In  a  general  way,  disease  of  the  tip  of  the  tongue  will  cause  enlarge- 
ment of  the  submental  nodes,  while  disease  of  the  frenum  might  cause 
enlargement  of  the  infrahyoid  group.  From  the  almost  universal  lack 
of  evidence  to  the  contrary,  one  might  be  led  to  believe  that  the  intra- 
oral nodes  are  not  liable  to  become  the  seat  of  secondary  deposits,  but 
Mikulicz  and  Kiimmel  state  that  the  nodes  between  the  geniohyoglossi 
muscles  are  frequently  involved  and  can  be  felt  to  be  enlarged  early  in 
the  disease. 

Disease  of  the  border  will  affect  the  submaxillary  nodes,  but  when 
situated  farther  back,  the  superior  deep  cervicals  will  be  first  invaded. 
These  divisions  of  territory  are  not  absolute  in  their  anatomical  arrange- 
ment, and  when  one  set  of  lymphatics  becomes  diseased,  new  channels 
through  anastomosis  are  sought,  so  that  eventually  the  spread  of  the 
disease  is  by  devious  routes.  For  these  reasons,  it  is  never  safe  to 
remove  only  a  group  of  nodes,  but  all  on  one  side  of  the  neck ;  at  least 
all  of  the  deep  and  superficial  cervicals  and  those  that  lie  in  front  of 
them  should  be  removed  in  every  case.  As  all  of  the  lymph  streams 
from  the  tongue,  with  the  exception  of  the  single  duct  that  goes  to  the 
subhyoid  nodes,  go  directly  or  indirectly  to  the  superior  deep  cervicals, 


CANCER  OF  THE  TONGUE. 


561 


these  latter  are  usually  among  the  earliest  to  become  palpable.  For 
this  reason,  it  has  been  customary  to  speak  of  the  one  enlarging  at  the 
level  of  the  hyoid  bone  as  the  principal  node  of  the  tongue  (Fig.  -iOS). 
When  the  disease  is  situated  at  the  tip  of  the  tongue,  or  on  the  root 
— that  is,  behind  the  circumvallate  papillae — or  when  the  disease  ex- 
tends to  the  median  line,  then  the  lymphatics  of  both  sides  may  be  easily 
infected.  In  the  later  stages  of  the  disease,  the  lymphatics  of  both 
sides  are  always  infected,  and  the  growth  in  the  neck  is  often  much 
more  rapid  than  in  the  tongue.  Rarely  the  nodes  opposite  to  the  site 
of  the  primary  growth  are  first  enlarged. 


Fig.  408.      Lymphatics  of  tlie  tongue. — After   Poirer. 

The  appearance  of  infected  lymph  nodes  varies  with  the  stage  of 
infection.  In  the  earliest  stages  the  nodes  may  be  so  soft  and  small  as 
not  to  be  detected  until  their  fascial  coverings  have  been  divided.  The 
smaller  nodes  appear  more  numerous  than  ordinary,  and  the  larger  ones 
are  soft  and  vascular.  On  opening  such  a  gland,  there  may  be  seen 
one  or  several  small,  white  points,  or  several  small  hemorrhages,  which 
latter,  according  to  Butlin,  are  a  suspicious  sign  if  the  gland  has  not 
been  roughly  handled.  Careful  microscopical  examination  may  show 
the  invading  epithelial  cells  or  the  beginning  of  epithelial  pearls,  but 
Butlin  is  of  the  opinion  that  the  microscope  may  not  be  able  to  demon- 


562  SURGERY  OF  THE  MOUTH  AND  JAWS. 

strata  the  epithelial  cells  in  these  earlier  gland  infections,  even  when 
the  gross  appearance  is  suggestive.  We  have  made  investigations  that 
led  to  the  same  conclusion.  In  the  more  advanced  lymphatic  infections 
the  typical  appearances  of  cancer  will  be  evident.  The  nodes  will  be 
enlarged  and  more  or  less  filled  with  hard,  white  tissue  that  may  cut 
like  cartilage,  and  usually  the  glands  will  be  seen  to  be  adherent  to 
neighboring  tissue.  Under  the  microscope  the  picture  at  this  stage  is 
unmistakable.  Later,  softening  of  the  nodes  or  open  ulceration  will 
be  found.  In  the  neck  carcinomatous  ulcers  are  usually  punched  out 
or  undermined. 

Clinical  Types  of  the  Mid-Period. — In  this  intermediate  stage 
the  objective  symptoms  described  are  as  a  rule  unmistakable,  but  the 
picture  may  vary  greatly  in  different  cases.  These  variations  are  due 
largely  to  the  extent  and  direction  of  the  growth,  both  locally  and  in 
the  lymph  nodes,  and  the  rapidity  with  which  ulceration  destroys  the 
new  tissue. 

Even  in  the  more  developed  stages  of  some  carcinomata,  there  may 
be  only  a  papillomatous  growth  surrounded  by  an  area  of  infiltration  at 
the  base,  or.  as  occurred  in  one  of  our  cases,  a  papilloma  covered  one 
fourth  of  the  dorsum,  but  was  indurated  only  in  one  small  spot.  In 
another  form  the  most  prominent  feature  may  be  an  ulcer  of  irregular 
outline,  surrounded  by  an  everted  edge  made  of  irregular,  hard,  small 
tubercles,  and  with  a  hard,  somewhat  limited  base  and  side  walls.  As 
in  one  illustrated  by  Butlin,  the  marginal  hard  border  nodules  may  be 
replaced  by  elevated  fleshy  masses,  the  floor  of  the  ulceration  being  oc- 
cupied by  a  slough.  The  ulceration  may  be  in  the  form  of  an  oval, 
scooped-out  gully  with  sloping"  sides,  the  base  and  sides  being  clean, 
glazed,  bright  red,  free  from  granulations,  and  extending  over  the 
elevated  edges,  abruptly  meeting  the  apparently  normal  mucous  mem- 
brane in  a  regular  smooth  outline.  In  this  stage  the  disease  is  apt  to 
be  absolutely  painless.  Instead  of  being  a  scooped-out  groove,  the 
ulceration  may  be  in  the  form  of  a  fissure,  marked  along  its  surface 
edges  by  a  few  irregular  nodules,  and  extending  deeply  into  the  sub- 
stance of  the  tongue.  When  the  edges  of  such  a  fissure  are  pulled 
apart,  the  anterior  is  found  to  be  lined  by  foul,  ragged  sloughs  and  to 
contain  decomposing  food  particles.  The  depth  of  the  fissure  can 
only  be  determined  with  a  probe,  while  the  immobility  of  the  tongue 
may  suggest  much  deeper  induration.  This  form  is  most  frequently 
seen  far  back  at  the  junction  of  the  under  surface  of  the  body  of  the 
tongue  with  the  floor  of  the  mouth,  and  from  the  proximity  of  the 
trunk  of  the  lingual  nerve,  may  be  extremely  painful  in  its  earliest 
stages.  In  the  sclerosing  cancer,  which  is  of  rare  occurrence,  the  sur- 
face may  be  depressed  and  but  little  ulcerated,  while  the  body  of  the 


CANCER  OF  THE  TONGUE.  563 

tongue  is  lessened  in  size,  but  contains  a  mass  of  board-like  hardness. 
In  these  types',  as  in  most  all  variations  of  the  picture,  the  essential 
features  of  carcinoma  are  sufficiently  evident  to  be  recognized  by  the 
careful  clinician.  The  tangible  and  visible  evidence  of  lymphatic  in- 
volvement varies  greatly  in  different  cases.  There  may  be  one  or  a  few 
hard  nodules  above  the  bifurcation  of  the  carotids,  or  the  whole  chain 
of  one  or  both  sides,  including  the  submaxillary  and  submental  nodes, 
may  be  involved.     In  the  early  stages  these  may  not  be  evident. 

General  Symptoms. — As  cancer  in  the  tongue  progresses,  espe- 
cially if  situated  farther  back,  difficulty  of  speaking  and  swallowing 
will  develop.  After  any  malignant  growth  has  persisted  for  some  time, 
it  tells  upon  the  general  constitution  and  is  evidenced  by  a  feeling  of 
malaise,  loss  of  weight,  and  a  peculiar  yellowish  color  of  the  skin  with 
the  loss  of  all  natural  color.  This  is  more  pronounced  in  the  late 
stages.  With  any  advanced  carcinoma  of  the  mouth,  the  loss  of  weight 
and  weakness  are  increased  by  the  difficulty  of  taking  food  and  the  loss 
due  to  the  salivation.  Later  in  the  disease,  a  foul  discharge  and  worse 
odor  are  always  present.  Anyone  who  has  ever  attended  a  neglected 
cancer  in  its  late  stages  is  likely  to  remember  the  odor  as  probably  the 
worst  that  may  be  associated  with  any  disease. 

FINAL  STAGE  OF  CARCINOMA  OF  THE  TONGUE. 

In  the  last  stage  of  the  disease  all  of  the  symptoms  mentioned  as 
belonging  to  the  mid-period  are  intensified.  The  tumor  extends  more 
rapidly,  and  some  other  local  structures — such  as  the  floor  of  the  mouth, 
jaw,  fauces,  pharynx,  or  palate — will  have  become  involved.  The 
tongue  may  be  fixed  in  the  floor  of  the  mouth  so  that  it  cannot  be  pro- 
truded. The  lymphatic  involvement  of  the  neck  may  be  very  extensive. 
Some  of  the  nodes  first  involved  may  have  broken  down,  involving  the 
skin  and  causing  induration  and  discoloration  or  craterous  ulcers. 
Before  the  skin  is  involved,  the  breaking-down  of  the  nodes  themselves 
may  be  detected  by  the  softening  or  fluctuation  present.  The  pain, 
salivation,  cancerous  discharge,  and  stench  all  unite  to  make  this  one 
of  the  most  terrible  of  diseases.  The  patient,  exhausted  by  lack  of  sleep 
and  food,  by  sepsis,  and  by  the  toxins  that  seem  essential  to  the  disease, 
loses  weight  rapidly  and  before  death  comes  is  usually  but  a  poor  rem- 
nant of  his  former  self.  If  the  growth  has  involved  the  glottis,  trache- 
otomy may  have  to  be  performed  to  prevent  suffocation. 

Death  from  Carcinoma  of  the  Tongue. — Like  carcinoma  of  the 
lip,  carcinoma  of  the  tongue  is  almost  essentially  a  local  disease  and, 
except  by  direct  extension  from  the  infected  lymphatics,  will  seldom 
invade  the  tissues  below  the  clavicle.  There  are  comparatively  few 
cases   recorded  where  it  has   affected  either  the  liver  or  the  lungs. 


564  SURGERY  OF  THE  MOUTH  AND  JAWS. 

These  are  estimated  at  about  1  per  cent  of  all  cases.  Death  comes 
usually  from  poisoning,  starvation,  and  exhaustion,  sometimes  from  a 
low  form  of  pneumonia.  It  rarely  comes  directly  as  the  result  of  hem- 
orrhage, but  repeated  losses  of  blood  no  doubt  often  hasten  the  end. 

DIAGNOSIS. 

The  diagnosis  is  to  be  made  from  the  symptoms  enumerated  and. 
at  least  in  the  very  early  and  doubtful  cases,  by  a  microscopical  exam- 
ination. In  the  very  early  stage,  chronicity  developing  induration, 
ulceration,  or  possibly  pain,  may  arouse  a  suspicion  of  the  nature  of 
the  disease;  or  the  appearance  of  the  lesion  may  be  sufficiently  typical 
to  warrant  a  tentative  diagnosis  of  cancer.  A  consideration  of  the  age 
and  sex,  and  probably  the  history  of  some  previous  chronic  lesion  that 
is  known  to  predispose  to  the  disease,  may  all  bring  affirmative  evi- 
dence. Early  in  the  second  stage,  induration,  ulceration,  and  active 
growth  will  be  present,  as  may  be  pain,  salivation,  or  a  discharge.  Be- 
fore the  cancer  becomes  evidently  beyond  the  scope  of  a  radical 
operation,  pain,  salivation,  discharge,  odor,  hemorrhage,  and  pro- 
nounced cachexia  may  one  or  all  have  disappeared,  but  none  of  them 
are  as  marked  as  they  will  be  later  in  the  disease.  Though  surgically 
extremely  important,  enlargement  of  the  lymph  nodes  should  be  a 
point  upon  which  the  surgeon  is  not  dependent  for  a  diagnosis.  When 
present,  it  is  to  be  accepted,  with  the  rest  of  the  evidence,  but  the 
chances  of  cure  by  operation  are  much  greater  if  the  growth  is  recog- 
nized and  removed  before  palpable  enlargement  of  the  nodes  occurs. 
As  a  contributory  evidence  of  this,  a  series  of  Butlin's  cases  may 
be  cited : 

Fifty-six  cases  in  which  the  results  are  known,  and  in  which  the 
glands  were  removed,  were  selected  for  a  basis.  In  one  of  these  cases 
the  submaxillary  gland  was  not  removed,  and  this  cannot  be  counted 
as  a  radical  gland  operation.  The  series  is  therefore  reduced  to  fifty- 
five  cases.  In  thirty-four  of  these,  glands  were  enlarged,  but  in  the 
majority  of  cases  not  demonstratively  cancerous  at  the  time  of  opera- 
tion. Seven  of  these  patients  died  of  recurrence  in  the  neck,  and 
eleven  were  cured.  Of  twenty-one  cases  in  which  the  glands  were  not 
enlarged  at  the  time  of  operation,  none  died  of  recurrence  in  the 
glands,  and  thirteen  were  cured  on  a  three-year  basis.  Reduced  to 
percentages,  the  results  of  the  two  series  are  as  follows :  When  the 
glands  were  enlarged,  20.6  per  cent  neck  recurrences  and  32.35  per  cent 
cures  on  a  three-year  basis ;  while  in  the  series  where  glands  were 
not  enlarged,  there  were  no  neck  recurrences  and  61.9  per  cent  cures. 
These  figures  should  be  a  sufficient  argument  against  requiring  gland- 
ular enlargement  as  an  essential  to  the  diagnosis.     Mikulicz  and  Kiim- 


CANCER  OF  THE  TONGUE.  565 

mel  go  so  far  as  to  state  that  the  disease  is  not  permanently  curable 
when  the  nodes'  become  palpable. 

Differential  Diagnosis. — Warty  growths,  simple  ulcers  and  fis- 
sures, tuberculous  infiltrations  or  ulcers,  primary  and  tertiary  syphilitic 
lesions,  and  other  granulomata  may  all  bear  a  close  resemblance  to 
carcinoma.  From  our  anxiety  to  make  an  early  diagnosis,  these  re- 
semblances may  be  annoying  or  misleading.  There  is  never  any  real 
excuse  for  being  seriously  misled  by  a  chancre.  Its  rapid  growth  and 
the  early  enlargement  of  the  lymph  nodes  should  excite  suspicion. 
The  presence  of  the  spirocheta  is  easily  demonstrated,  and  if  seen 
after  the  first  few  weeks,  the  secondary  lesions  will  probably  settle  the 
question.  Noguchi  claims  that  it  is  impossible  to  differentiate  micro- 
scopically, with  either  dark  stage  or  stained  specimens,  between  Spiro- 
cheta pallida  and  Spirocheta  niicrodentium,  and  that  the  diagnosis 
between  these  two  can  be  made  only  by  culture,  microdentium  culture 
giving  an  odor  and  pallida  none.  Unbroken  gumma  or  the  ulcer  re- 
maining after  the  breaking-down  of  a  gumma  may  present  more  serious 
difficulties.  As  described  by  Butlin,  in  their  early  stages  an  unbroken 
gumma  and  a  deep  carcinoma  may  have  the  following  points  in  com- 
mon :  slow  development ;  an  ill-defined  outline  not  separable  from 
the  tissues  of  the  tongue;  both  diseases  prone  to  occur  in  the  dorsum 
of  the  tongue,  and  in  men  over  thirty.  They  may  differ  in  the  follow- 
ing points :  gummata  are  often  multiple ;  carcinomata  rarely  so.  Intra- 
oral tertiary  syphilitic  lesions  rarely  occur  by  themselves,  there  usually 
being  other  marks  of  the  disease  in  other  parts  of  the  body,  but  there 
is  nothing  to  preclude  a  carcinoma  from  developing  in  a  syphilitic  or 
from  an  old  syphilitic  scar.  The  difficulty  in  differentiating  between 
the  two  may  be  so  great  as  to  be  settled  only  by  time,  or  a  microscopical 
examination.  Time  spent  in  watching  an  early  carcinoma  is  valuable 
time  wasted,  and  if  the  diagnosis  cannot  be  made,  it  should  be  treated 
as  a  carcinoma. 

Almost  the  same  difficulties  may  arise  in  distinguishing  between  an 
ulcerating  gumma  and  a  carcinoma.  Gummatous  ulcers  are  most  fre- 
quently met  with  on  the  dorsum ;  while  deeply  ulcerating  early  carci- 
nomata are  most  frequent  upon  the  borders.  The  edges  of  a  gumma- 
tous ulcer  are  usually  undermined ;  while  on  the  tongue  the  borders  of 
a  cancer  are  never  undermined,  afid  are  indurated  to  a  much  greater 
extent  than  those  of  a  gummatous  ulcer.  The  floor  of  a  carcinomatous 
ulcer  is  covered  by  a  slough  or  granulations  that  bleed  when  disturbed ; 
while  the  floor  of  a  gummatous  ulcer  may  contain  a  tough  laminated 
membrane  that  can  be  peeled  off  in  pieces  with  little  bleeding.  Carci- 
noma is  always  more  likely  to  bleed  than  is  an  open  gumma,  and  in  the 
former  pain  is  a  more  common  symptom.     Gummatous  ulcers  are  often 


566  SURGERY  OF  THE  MOUTH  AND  JAWS. 

multiple;  cancer  almost  never  so.  After  a  cancerous  ulcer  has  per- 
sisted for  some  time,  the  glands  will  become  enlarged,  which  does  not 
occur  with  gumma. 

The  common  practice  of  making  a  differential  diagnosis  by  means 
of  the  therapeutic  test  is  open  to  two  serious  objections:  the  most 
important  is  the  time  lost  in  the  presence  of  carcinoma ;  and  the  other, 
that  after  a  severe  course  of  mercury  and  iodid  the  mucous  membrane 
of  the  mouth  becomes  more  or  less  inflamed,  and  the  patient  is  de- 
pressed and  less  resistant  to  infection.  If  in  this  condition  an  operation 
is  done,  the  risks  are  increased. 

The  serum  tests  are  not  open  to  the  latter  objection,  and  where  the 
means  are  available,  Wassermann,  Noguchi,  and  luetin  tests  may  be 
applied  in  doubtful  cases.  Even  if  these  tests  are  positive  or  negative, 
the  information  is  not  so  reliable  as  is  that  derived  from  a  properly 
made  microscopical  examination.  These  tests  may  not  invariably  be 
positive  in  the  presence  of  tertiary  lesions,  and  it  is  possible  that  the 
reaction  may  occur  in  other  disease  than  lues.  Even  if  positive,  they 
do  not  preclude  cancer,  and  some  late  observations  suggest  that  cancer 
is  one  of  the  diseases  that  may  cause  a  positive  Wassermann  reaction. 
With  reference  to  the  therapeutic  test  Butlin  states : 

"The  reason  that  leads  us  to  speak  so  strongly  of  the  microscopical 
examination  is  that  we  have  seen  many  cases  in  which  carcinomatous 
ulcers  have  been  treated  as  syphilitic  ulcers  by  some  of  the  best  clinical 
surgeons  in  London,  not  because  they  felt  sure  the  disease  was  syphi- 
litic, but  because  they  could  not  feel  sure  whether  it  was  cancerous  or 
syphilitic.  Weeks  were  allowed  to  elapse  in  this  manner  until  the 
ulcer  had  clearly  shown  that  it  was  not  in  the  least  affected  by  anti- 
syphilitic  treatment,  and  perhaps  had  implicated  the  lymphatic  glands 
The  period  at  which  it  should  have  been  removed  was  allowed  to  pass, 
and  the  operation  was  undertaken  when  the  prospect  of  ultimate  suc- 
cess was  exceedingly  small  and  when  the  patient  was  weakened  by 
large  doses  of  iodid  of  potassium,  and  in  one  case  by  mercurial  saliva- 
tion." 

Head  cites  a  case,  exhibited  by  H.  Burt,  in  which  a  young  woman, 
twenty-four  years  of  age,  had  a  cancer  of  the  tongue  which  shrank 
materially  under  the  use  of  iodid,  only  to  later  grow  rapidly  while 
under  the  same  treatment.  He  calls  attention  to  the  fact  that  iodids 
may  cause,  for  a  time,  a  prompt  reduction  of  a  malignant  growth. 

The  diagnosis  between  tubercle  and  carcinoma  is  even  more  diffi- 
cult. But  primary  tuberculous  ulcers  of  the  tongue  are  rare ;  and  even 
when  secondary  ulcers  closely  simulate  carcinoma,  the  presence  of  the 
primary  lesions,  usually  in  the  respiratory  passage  and  lungs,  should 
suggest  the  probability  of  the  same  disease  in  the  mouth.     Even  here, 


CANCER  OF  THE  TONGUE.  567 

the  conclusion  cannot  be  certain,  for  tuberculous  infection  in  the  lung 
does  not  preclude  carcinoma  of  the  mouth.  Here,  again,  the  micro- 
scope can  be  a  most  helpful  agent,  but  only  when  used  by  one  of  great 
experience. 

Between  a  simple  papilloma  and  a  carcinoma  the  diagnosis  should 
be  made  by  the  microscope.  The  papilloma  should  always  be  removed. 
If  the  wart  arises  in  a  patch  of  leucoplakia  or  chronic  glossitis,  it  may 
be  regarded  as  carcinoma.  Between  simple  ulcers  and  carcinoma  the 
diagnosis  is  often  difficult.  This  is  made  more  so  by  the  knowledge 
that  carcinoma  can  develop  in  a  simple  ulcer.  The  persistence  or 
spreading  of  the  ulcer  and  induration  after  removal  of  the  apparent 
cause  should  be  regarded  as  very  suspicious. 

Chronic  abscess  may  be  mistaken  for  deep  carcinoma.  In  a  case 
referred  to  on  page  417,  it  was  only  after  a  microscopical  examination 
had  been  made  of  the  wall  of  the  abscess  that  we  believed  that  we  did 
not  have  to  deal  with  a  broken-down  carcinoma.  The  wall  of  the  abscess 
was  of  such  hardness  that  it  appeared  typical  of  cancer,  though  the 
location  was  unusual  for  the  latter  disease. 

Butlin  remarks :  "Until  the  last  few  years  it  was  almost  universal 
in  the  profession  to  regard  a  carcinomatous  ulcer  as  probably  and  then 
possibly  an  ulcer  of  some  other  kind  until  it  was  clearly  proved  to  be 
carcinoma  by  unmistakable  signs.  Yet  even  among  'men  of  experi- 
ence' there  was  a  fatal  tendency  to  do  what  is  commonly  termed  'give 
the  patient  a  chance'  by  treating  the  disease  on  the  assumption  that  it 
was  syphilitic  or  simple.  Gradually  medical  men  are  coming  around 
to  the  belief  that  'to  give  the  patient  a  chance'  means  under  such  cir- 
cumstances to  'gire  the  carcinoma  a  chance'  of  obtaining  a  Urm  hold 
and  to  take  all  chances  of  complete  recovery  from  the  patient." 

Microscopical  Diagnosis. — If  we  are  to  cure  a  large  percentage 
of  cancers,  it  is  to  be  done,  according  to  our  present  state  of  know- 
ledge, only  by  operations  done  at  a  time  when  from  clinical  signs  alone 
the  diagnosis  will  in  most  cases  be  still  a  matter  of  some  doubt.  To 
give  us  the  courage  to  do  a  sufficiently  radical  operation,  there  is  no 
help  like  microscopical  findings.  Unfortunately  this  means  of  diag- 
nosing early  carcinoma  of  the  tongue,  which  ought  to  be  employed  in 
every  doubtful  case,  has  been  greatly  discredited.  While  there  is  no 
doubt  that  in  many  instances  the  surgeon  has  been  led  astray,  this  does 
not  mean  that  there  are  not  men  whose  training  and  technique  make 
them  competent  to  render  an  opinion  that  at  least  will  not  be  misleading. 
It  has  been  our  good  fortune  to  have  had  extremely  satisfactory  results 
from  the  men  upon  whom  we  have  learned  to  rely. 

The  most  confusing  thing  about  the  histological  appearance  of  some 
carcinomata  is  the  overwhelming  infiltration  of  round  cells  that  may 


568  SURGERY  OF  THE  MOUTH  AND  JAWS. 

partially  destroy  and  completely  obscure  the  invading  epithelial  cells. 
On  account  of  this,  malignant  disease  has  been  mistaken  for  innocent 
ulceration,  but  repeated  examinations  of  several  sections  from  one  or 
several  carefully  selected  specimens  that  include  a  part  of  the  appar- 
ently healthy  neighboring  tissue  will  most  likely  reveal  cell  nests  or 
columns  of  invading  epithelial  cells,  if  they  are  present.  There  are 
normally  occasional  apparent  cell  nests  in  the  mucous  membrane,  but 
these  will  not  mislead  an  experienced  pathological  microscopist.  When 
doubt  exists  as  to  the  microscopical  findings,  the  surgeon  has  still  the 
clinical  data  to  guide  him,  which,  if  carefully  studied,  will  rarely  be 
negative  or  misleading,  except  in  the  very  earliest  cases;  and  these 
being  small  had  best  be  removed  if  there  is  any  doubt  of  their  character. 

The  differentiation  between  tubercle  and  epithelioma  may  be  still 
more  difficult,  but  there  are  special  tests  that  may  confirm  and  exclude 
tubercle ;  the  distinction  is  not  of  so  great  importance  as  with  other  in- 
flammatory growths,  as  the  treatment  of  carcinoma  and  tuberculosis  of 
the  mouth  is  almost  essentially  the  same  (see  page  364). 

DIFFERENTIATION   BETWEEN   OPERABLE  AND 
NON-OPERABLE  CARCINOMATA. 

The  diagnosis  of  cancer  in  the  third  stage  presents  few  difficulties 
unless  it  be  confounded  with  tuberculosis,  syphilis,  or  mycosis.  To  de- 
termine whether  an  advanced  carcinoma  is  operable  or  inoperable  is 
often  quite  another  matter  and  must  be  decided  by  good  judgment  and 
nice  observation,  rather  than  by  any  special  rule  of  thumb.  Although 
it  is  not  uncommon  to  hear  good  observers  remark  upon  the  fact  that 
carcinoma  usually  extends  farther  than  the  external  appearance  indi- 
cates and  that  when  there  is  any  doubt  that  the  case  is  operable  it 
is  almost  certain  to  be  inoperable,  still,  if  there  is  any  reasonable  doubt 
of  its  not  having  gone  beyond  the  surgeon's  reach,  if  the  patient  is 
willing,  and  if  his  general  condition  warrants  it,  he  should  be  given 
the  benefit  of  the  doubt,  and  the  operation  should  be  performed. 

The  virulency  of  the  growth  has  much  to  do  with  the  prognosis, 
and  this  varies.  As  evidence  that  an  advanced  case  may  not  be  hope- 
less, we  may  cite  a  case  of  Butlin's  operated  on  in  1903,  in  which  at 
operation  he  found  a  mass  of  glands  in  the  neck  that  he  considered 
irremovable.  Later  he  "summoned  up"  his  courage  and  again  attacked 
this  mass  of  glands,  which  were  removed  with  great  difficulty.  In 
1908,  he  received  word  from  the  family  physician  that  the  patient  was 
perfectly  well. 

There  are  three  factors  to  be  taken  into  consideration  in  determin- 
ing the  operability  of  a  case :  the  extent  of  the  disease ;  the  condition 
of  the  patient  in  reference  to  the  probability  of  being  able  to  withstand 
the  effects  of  one  or  several  extensive  operations ;  and  the  experience 


CANCER  OF  THE  TONGUE.  569 

and  ability  of  the  surgeon.  If  the  local  growth  is  confined  to  the 
tongue,  it  is  aiways  to  be  considered  operable  unless  the  tissues  of  the 
neck  are  involved  well  outside  the  lymph  nodes.  If  it  has  involved 
the  floor  of  the  mouth  on  one  side  and  even  the  jaw,  or  has  extended 
to  the  wall  of  the  pharynx  or  palate,  the  case  may  still  be  curable ;  but 
the  risk  from  the  operation  is  greatly  increased,  and  the  chances  of 
success  are  small.  If  in  a  pharyngeal  or  faucial  involvement  the 
finger  can  be  passed  well  beyond  the  posterior  limit  of  a  growth  that 
is  movable  upon  the  deeper  structures,  its  removal  may  still  be  under- 
taken with  a  faint  hope  of  ultimate  success.  In  order  to  make  this 
examination,  it  may  be  necessary  to  paint  or  spray  the  velum,  fauces, 
and  pharyngeal  wall  with  a  5  per  cent  solution  of  novocain.  Before 
deciding  that  a  patient  who  has  suffered  from  pain,  and  lack  of  sleep 
and  food,  is  too  weak  for  operation,  it  should  be  determined  what  a  few 
days  of  rest,  freedom  from  pain,  and  proper  treatment  will  do  for  him. 
A  patient  who  has  been  reduced  by  repeated  hemorrhages  may  some- 
times be  greatly  helped  by  a  blood  transfusion. 

While  a  patient  who  dies  as  a  result  of  the  operation  may  be  con- 
sidered better  off  than  he  who  lingers  through  the  terminal  stages  of 
a  carcinoma  of  the  mouth,  no  one  may  undertake  a  radical  operation 
on  a  case  that  he  knows  to  be  hopeless.  Besides  not  having  the  right 
to  subject  a  patient  to  useless  danger,  there  is  the  important  considera- 
tion that  every  death  after  operation  is  a  discredit  to  our  surgery,  and 
is  liable  to  deter  some  other  patient  from  the  benefits  of  a  necessary 
operation. 

If  the  attempt  at  local  removal  is  a  failure,  and  the  disease  returns 
in  situ,  m  a  few  weeks  or  months,  then  the  patient  is  even  worse  off, 
and  as  Childe  remarks,  "it's  better  to  let  him  die  once  than  twice." 
Even  local  removals  should  not  be  attempted  when  they  offer  no  hope 
of  local  eradication.  But  if  the  primary  growth  can  be  removed,  much 
is  gained  by  the  patient,  for  the  cervical  growth  is  easier  to  care  for 
and  gives  less  discomfort  that  the  intraoral  ulcer.  Crile's  radical  oper- 
ation on  the  lymph  nodes  and  their  surrounding  tissues  greatly  lessens 
the  number  of  lymphatic  recurrences. 

PROGNOSIS  OF  CARCINOMA  OF  THE  TONGUE. 

When  unoperated  upon,  the  certain  result  is  death,  and  in  a  dis- 
tressing form.  The  average  duration  of  life  with  an  unoperated  carci- 
noma of  the  tongue  is  placed  by  Butlin  and  von  Bergmann  at  about 
one  year.  DaCosta  extends  the  limit  to  a  possible  two  years,  while 
very  young,  or  greatly  debilitated,  subjects  may  survive  but  a  few 
months.  Even  with  careful  and  extremely  radical  operations,  the 
ultimate  prognosis  of  the  majority  of  cases  that  show  all  of  the  typical 
symptoms  is  little  better.     For  cancer  operated  on  in  the  early  stages 


570  SURGERY  OF  THE  MOUTH  AND  JAWS. 

— that  is,  before  they  assume  the  classic  picture  which  in  the  past  has 
been  too  frequently  demanded  for  a  diagnosis — the  prognosis  is  very 
dififerent. 

Results  of  Operation. — The  so-called  cures  are  cases  that  live 
three  years  without  recurrence.  The  length  of  time  these  patients 
will  survive  after  three  years  varies,  but  it  is  a  noticeable  fact  that  after 
three  years  recurrences  are  comparatively  few. 

Butlin's  final  results  are  based  on  200  cases.  Of  these,  33  are  not 
counted — the  operation  was  abandoned,  the  patient  was  lost  sight  of, 
the  operation  was  too  recent,  or  the  patient  had  died  of  some  other 
disease  within  the  three  years.  Including  the  operative  deaths,  but  ex- 
cluding unoperated,  recent,  and  untraceable  cases,  out  of  168  cases,  there 
were  57  recoveries  traced  for  periods  varying  from  three  to  twenty-two 
years  without  recurrence,  which  is  33.92  per  cent  cures,  with  an  oper- 
ative mortality  of  10  per  cent.  Possibly  one  or  two  cases  supposed  to 
have  died  of  other  causes  might  have  been  affected  by  distant  metas- 
tasis, but  this  would  not  greatly  affect  the  general  result.  In  many 
of  the  200  cases  the  lymph  nodes  were  not  removed,  and  in  a  number 
of  the  earlier  cases  the  lymphatic  removal  was  very  limited.  In  the 
second  half  of  this  series  the  results  are  still  better.  In  99  cases  out 
of  the  first  197,  there  were  22  cases  not  counted,  because  too  recent,  the 
patient  was  lost  sight  of,  the  operation  was  not  completed,  or  was  only 
palliative.  Of  the  77  remaining  cases,  32  were  successful,  which  gives 
41.55  per  cent  of  cures  in  cases  subjected  to  a  radical  operation  and 
traced  for  over  three  years.  Warren  places  cures  at  17.5  per  cent. 
Dollinger,  of  Buda  Pesth,  stated  before  the  Second  Brussels  Congress 
that  of  23  cases  of  cancer  of  the  tongue  69  per  cent  died  within  the  first 
year  and  not  one  survived  three  years ;  and  the  result  given  to  Butlin 
by  a  prominent  Australian  surgeon  made  little  better  showing.  Many 
more  statistics  could  be  quoted,  but  they  would  fall  between  these  ex- 
tremes. The  prognosis  of  cases  operated  on  for  recurrence  is  very  bad, 
but  occasionally  one  has  been  cured. 

TREATMENT  OF  CARCINOMA  OF  THE  TONGUE. 

The  treatment  of  any  operable  case  of  cancer  is  its  entire  removal 
locally,  and  removal  of  the  infected  lymph  areas.  The  burning-out 
of  a  cancer  of  the  tongue  is  to  be  condemned,  both  on  account  of  the 
fact  that  it  cannot  destroy  cells  in  the  deeper  tissues  and  because  the 
resulting  scar  is  of  the  kind  that  predisposes  to  the  formation  of  can- 
cer. Of  the  use  of  the  x-ray,  various  reports  have  been  given,  but  we 
must  not  be  blinded  by  the  reports  made  by  enthusiasts  before  sufficient 
time  has  elapsed  to  allow  of  final  judgment.  The  opinion  of  most 
surgeons  is  that  while  the  x-ray  will  destroy  cancer  cells  on  the  sur- 
face its  penetration  is  not  sufficient.     Radium  will  also  destroy  surface 


CANCER  OF  THE  TONGUE.  571 

growths,  but  is  open  to  the  same  objections  as  is  the  x-ray.  Surface 
epitheliomata-have  been  destroyed  by  x-ray,  by  radium,  and  by  purely 
local  excision,  but  these  successes  should  not  deter  us,  when  we  are 
allowed  to  choose,  from  the  practice  that  is  known  to  give  the  best 
chance  to  the  greatest  number. 

The  extent  to  which  the  operation  is  to  be  carried  is  always  a  diffi- 
cult question  to  decide,  and  is  often  complicated  by  the  general  condi- 
tion of  the  patient.  On  the  one  hand,  the  surgeon  knows  that  he  is 
dealing  with  a  disease  that  must  be  entirely  removed,  and  which  in 
many  instances  is  limited  to  the  mouth  and  certain  tissues  of  the  neck 
that  are  perfectly  accessible  to  dissections.  On  the  other  hand,  the 
patient  is  often  enfeebled  by  dissipation,  age,  or  cachexia,  possibly  all 
three,  and  is  not  an  ideal  subject  for  a  prolonged  operation.  The 
mouth  is  a  septic  cavity.  By  making  extensive  wounds  that  expose 
the  great  vessels  and  deep  facial  planes  of  the  neck  which  communicate 
with  the  mouth  by  operative  wound  or  through  the  efferent  lymph 
ducts,  one  adds  the  risk  of  sepsis  to  that  of  operative  shock.  Hemor- 
rhage is  a  serious  consideration,  not  only  on  account  of  the  direct 
effects  of  the  loss  of  blood,  but  hemorrhage  within  the  mouth  obscures 
the  operative  field  and  increases  the  risk  of  aspiration  into  the  trachea. 
Finally,  any  operative  interference  with  the  floor  of  the  mouth  and  the 
posterior  part  of  the  tongue  is  apt  to  be  followed  by  a  low  form  of 
septic  pneumonia,  which  is  the  most  frequent  form  of  operative  death. 

The  loss  of  the  tongue  itself,  especially  if  only  two  thirds  or  a 
lateral  half  is  removed,  is  not  so  serious  a  deformity  as  one  would  at 
first  imagine.  If  the  patient  survives  the  first  few  days,  he  can  swallow 
liquids.  Even  where  the  amputation  extended  to  within  1  centimeter 
of  the  epiglottis,  we  have  seen  a  patient  take  fluids  and  make  partially 
intelligible  attempts  at  speech  within  a  day  after  operation.  With  a 
fair-sized  stump  remaining,  speech  is  surprisingly  good. 

When  a  surgeon  is  confronted  with  a  supposedly  operative  case  of 
carcinoma  of  the  tongue,  he  at  once  meets  these  very  serious  questions : 
how  far  is  it  necessary  for  him  to  go  in  his  attempt  to  remove  the  dis- 
ease, and  how  best  can  he  do  this  with  least  risk  to  life?  Very  often 
the  question  reduces  itself  into  not  how  far  he  should  go,  but  how  far 
can  he  go  without  assuming  risks  that  are  unwarranted  even  in  dealing 
with  carcinoma.  The  answers  proposed  to  these  questions  by  surgeons 
of  large  observation  and  experience  in  this  special  line  are  often  some- 
what divergent.  One  of  less  experience  is  left  with  the  alternative  of 
studying  the  methods,  teachings,  and  results  of  one  school,  better  still 
of  one  man,  or  of  attempting  to  analyze  and  to  profit  by  the  experience 
of  many  and  steer  his  course  accordingly.  The  latter  is  a  very  large 
order,  and  he  who  attempts  it  must  beware,  lest  between  two  stools  he 


572  SURGERY  OF  THE  MOUTH  AND  JAWS. 

fall,  which  is  most  likely  to  happen  if  he  attempts  to  follow  the  more 
radical  teachings  of  some  men  without  having  either  their  skill  or  their 
clinical  experience,  or  if  he  undertakes  to  mix  technical  methods  without 
having  thoroughly  mastered  the  motifs  and  problems  of  each.  The 
following  are  some  of  the  questions  that  will  arise  with  every  case : 

(a)  When  ShouIvD  the  Operation  Be  Done? — This  should  be 
as  early  as  possible,  but  in  cases  where  the  mouth  is  septic  and  those  in 
which  the  patient  is  in  a  poor  physical  condition,  a  few  days  may  be 
well  spent  in  preparation. 

(b)  The  Extent  oe  the  Local  Excision? — Heidenhain  main- 
tains that  a  bilateral  excision  should  be  made  in  every  case,  but  Butlin 
has  denounced  this  practice  strongly ;  and  both  he  and  Kocher  are  con- 
tent to  make  the  excision  2  centimeters  beyond  the  evident  involvement. 
Warren  advocated  an  inch,  and  he  believes  that  for  want  of  free  re- 
moval most  recurrences  are  local.  These  directions  refer  to  the  mus- 
cular tissue  of  the  tongue  and  the  muscle  sheaths.  Carcinoma  of  the 
tongue  does  not  spread  so  rapidly  in  the  mucous  membrane  and  extra 
muscular  cellular  tissue  as  it  does  in  the  substance  of  the  muscles,  and 
tends  especially  to  spread  along  the  length  of  an  affected  muscle.  It 
tends  to  spread  more  rapidly  toward  the  base  than  toward  the  tip, 
and  in  front  of  the  vallate  papillae  does  not  readily  cross  the  median 
septum.  These  points  should  be  considered  in  planning  the  excision. 
It  would  seldom  be  practical  to  make  a  block  excision  including  all 
tissues  for  a  distance  of  2  centimeters  or  an  inch  beyond  the  growth. 
Kocher  makes  his  incision  in  the  mucous  membrane  of  the  floor,  1 
centimeter  beyond  the  growth. 

Mr.  Lenthal  Cheatle,  who  has  been  carrying  on  the  research  for 
several  years,  has  found  in  microscopical  sections  of  the  muscles,  at  a 
considerable  distance  from  the  primary  disease,  columns  of  cancer  cells 
lying  between  the  fibers  of  the  muscles,  that  look  quite  healthy  to  the 
naked  eye.  He  therefore  recommends  that  the  hyoglossus  and  genio- 
hyoglossus  and  the  inferior  lingualis  muscle  should  be  removed  in  every 
early  case  of  cancer  of  one  half  of  the  tongue,  even  if  the  primary  dis- 
ease is  quite  small  and  in  an  early  stage  of  existence. 

Butlin,  however,  believes  that  his  observations  warrant  the  opinion 
that,  with  the  possible  exception  of  cases  where  a  preoperative  micro- 
scopical examination  of  the  tissues  shows  the  growth  to  be  of  unusual 
malignancy,  and  of  those  cases  where  the  primary  growth  is  very  ex- 
tensive, a  block  excision,  which  includes  the  whole  of  one  or  both 
geniohyoglossi  muscles  and  extends  three  quarters  of  an  inch  beyond 
the  evident  growth,  is  the  proper  routine  practice. 

In  102  out  of  200  cases,  the  patient  either  died  of  recurrence  at 
some  other  site,  or  was  alive  and  well  after  three  years  without  re- 


CANCER  OF  THE  TONGUE.  573 

currence  in  the  mouth  scar.  Of  33  cases  in  which  recurrence  is  known 
to  have  taken  place  in  the  mouth  scar,  the  growth  was  extensive  in 
most  of  them  at  the  time  of  operation,  and  in  only  three  did  he  feel 
that  a  more  extensive  local  excision  would  have  given  better  promise, 
(c)  The;  Character  of  the  Locai,  Operation? — Butlin  prefers 
the  intraoral  operation.  This  is  done  through  the  mouth,  with  or 
without  splitting  the  cheek.  In  all  cases  in  which  the  jaw-bone  is  not 
directly  involved,  the  low  operative  mortality  is  a  very  strong  argument 
in  its  favor.  Kocher  considers  that,  for  the  intraoral  operation  to  be  ap- 
propriate, the  tumor  must  be  freely  movable  on  the  jaws  and  floor  of 
the  mouth,  and  must  be  so  placed  that,  after  the  application  of  toothed 
compression  forceps  to  the  body  of  the  tongue  behind  the  growth,  there 
will  be  room  enough  to  make  the  excision  in  front  of  the  forceps.  If 
the  growth  extends  back  to  the  faucial  pillars,  he  performs  his  "normal 
excision,"  which  includes  splitting  the  jaw-bone  and  floor  of  the  mouth 
in  the  median  line  (see  page  588).  For  complete  excision  of  the 
tongue,  Kocher  uses  the  operation,  which  he  has  described  as  excision 
of  the  tongue  at  its  root  (see  page  589).  Carcinoma  of  the  base  of  the 
tongue  may  be  removed  through  a  transverse  suprahyoid  incision,  but 
when  the  jaw  is  directly  involved,  a  section  of  the  bone  must  be  re- 
moved as  part  of  the  block  excision. 

An  idea  of  the  relative  mortality  of  these  various  operations  may  be 
gained  from  the  following  figures :  In  101  cases  operated  on  by  the 
oral  route,  Whitehead  had  3  per  cent  postoperative  deaths ;  but  in  38 
complicated  cases,  he  had  17  deaths,  a  death  rate  of  44.73  per  cent. 
Butlin  does  not  state  specifically  just  how  many  of  his  cases  were 
operated  on  by  the  intraoral  route,  but  from  his  teachings  it  is  fair  to 
surmise  that  the  majority  were.  In  the  last  102  of  his  200  cases,  there 
were  9  deaths  resulting  from  operation,  which  is  8.82  per  cent.  In 
the  200  cases,  there  were  20  operative  deaths,  or  10  per  cent.  While 
the  first  mentioned  series  shows  little  improvement  in  the  death  rate, 
here  the  average  operation  was  more  extensive  than  in  the  earlier  cases. 
The  causes  of  death  in  the  20  cases  are  as  follows : 

Died   suddenly  during  operation 1 

Sepsis  of  wound 1 

Septic   pneumonia 10 

Subsequent   hemorrhage 3 

Shock    2 

Sufifocation  (sudden  a  week  after  operation) 1 

Heart   failure   some  days   after  operation,   feeble   pa- 
tient,  77   years  old 1 

Acute  mania   (without  sepsis) 1 

20  cases 


574  SURGERY  OF  THE  MOUTH  AND  JAWS. 

In  a  series  of  62  cases  operated  on  by  Kocher,  between  1890  and 
1893,  23  were  operated  on  through  the  mouth,  with  or  without  spHtting 
the  cheek;  of  these  one  died,  a  mortality  of  4.34  per  cent.  Seven  were 
complete  excision  from  the  root ;  of  these  one  died. 

In  29  cases  reported  by  Warren,  operated  from  below  the  jaw,  there 
were  3  deaths,  or  10.3  per  cent.  Butlin  estimates  the  mortality  of  this 
operation,  from  62  collected  cases,  as  20  per  cent. 

Of  23  cases  of  Kocher's  in  which  the  jaw  and  floor  of  the  mouth 
were  split  in  the  median  line,  4  died,  a  mortality  of  17.39  per  cent. 
While  in  4  cases  it  was  split  laterally  and  in  3  a  piece  of  the  bone  was 
excised;  of  these  7  cases  2  died. 

In  13  operations,  reported  by  Warren,  in  which  the  jaw  was  di- 
vided, there  was  a  mortality  of  30.7  per  cent.  Sachs  gives  the  mor- 
tality of  this  operation  in  Kocher's  clinic  as  19  per  cent,  while  Butlin 
places  it  at  25  per  cent. 

Loison  places  the  death  rate  of  simple  operations  at  10.7  per  cent, 
while  of  the  more  complicated  ones  at  23  per  cent. 

Of  course  the  choice  of  method  does  not  always  rest  with  the 
operator,  but  it  will  be  seen  from  these  figures  that  where  the  operation 
is  performed  within  the  mouth  the  postoperative  death  rate  is  remark- 
ably low  in  comparison  with  those  cases  in  which  the  bone  is  divided. 

(d)  Should  the;  Lymphatics  of  the  Neck  Be  Removed  in 
Every  Case? — This  question  will  not  arise  in  connection  with  cases 
where  the  lymph  nodes  are  palpably  enlarged,  unless  the  disease  is 
apparently  hopelessly  advanced.  With  the  very  early  cases,  however, 
believing  that  for  an  uncertain  time  the  lymph  nodes  may  be  immune, 
one  might  hesitate  to  subject  the  patient  to  an  extra  operation,  unless 
it  could  be  shown  that  the  chances  for  cure  are  thereby  materially  in- 
creased. Certain  series  of  published  cases  might  at  first  lead  one  to 
think  that  this  is  not  a  wise  routine  procedure.  In  a  series  of  18  early 
cases,  cited  by  Butlin,  there  were  8  cures.  In  6  of  the  8  cured  cases, 
the  glands  were  not  removed.  Warren  reports  a  similar  series.  Out 
of  19  very  early  cases,  he  had  8  cures,  and  in  only  one  of  the  8  cured 
cases  were  the  glands  removed.  These  cures  are  figured  on  a  three- 
year  basis.  Butlin  reports  one  case,  in  which  infection  of  the  unre- 
moved  glands  became  evident  three  and  one  half  years  after  a  success- 
ful mouth  operation.  In  neither  of  these  series  is  the  number  of  cases 
stated  in  which  the  glands  were  removed,  nor  the  condition  of  the  glands 
at  the  time  of  operation.  Therefore  the  only  conclusion  that  can  be 
drawn  from  them  is  that  certain  early  cases  will  remain  free  of  glandu- 
lar recurrence,  for  three  years,  even  when  the  glands  are  not  removed. 

In  the  following  data,  worked  out  from  Butlin's  full  reports,  an 
attempt  had  been  made  to  get   some  basis   for  comparing  the  per- 


CANCER  OF  THE  TONGUE.  5?5- 

centage  of  glandular  recurrences,  with  and  without  their  removal.  In 
a  series  of  4-1  cases  in  which  the  glands  were  not  removed,  in  5  the 
glands  were  enlarged  at  the  time  of  operation,  6  died  of  operation,  8 
died  of  recurrence  in  the  mouth,  and  3  other  cases  were  not  tabulated, 
making  a  total  of  22  cases  not  appropriate  for  our  present  purpose. 
In  the  22  remaining  cases  in  which  the  glands  were  not  removed,  they 
were  not  palpable  at  time  of  operation;  the  patients  survived  opera- 
tion, were  traced  afterward,  and  had  no  mouth  recurrence.  Of  these  22 
patients,  10  died  of  glandular  recurrence,  which  is  45.45  per  cent. 

In  a  series  of  70  cases,  in  each  of  which  the  contents  of  the  anterior 
triangle  were  removed,  6  died  of  operation,  1  was  lost  sight  of,  10 
died  of  recurrence  in  the  mouth,  7  died  of  recurrence,  site  unknown, 
and  12  others  were  not  tabulated — a  total  of  36  cases  not  to  be  included. 
Of  the  remaining  34  cases  which  survived  operation  without  mouth 
recurrence  and  which  were  traceable,  but  8  died  of  glandular  recurrence 
of  the  same  side  and  2  of  the  opposite  side.  This  gives  neck  recur- 
rences after  glandular  removal  as  27.77  per  cent  against  45.45  per  cent 
recurrences  where  the  lymph  nodes  were  not  removed  and  were  appar- 
ently not  enlarged.  While  the  number  of  cases  available  is  small, 
the  figures  are  at  least  suggestive,  and  an  extremely  significant  fact 
is  the  following:  Out  of  the  34  cases  selected  from  the  series  of 
70  in  which  the  glands  of  the  anterior  triangle  of  one  side  were  re- 
moved, 8  are  known  to  have  died  of  glandular  recurrence  of  the  same 
side,  but  7  of  these  8  cases  had  enlarged  glands  at  the  time  of  oper- 
ation; and  in  the  remaining  case  the  operation  was  incomplete,  inas- 
much as  the  submaxillary  salivary  gland  was  not  removed  and  the 
recurrence  was  at  this  site.  Subtracting  the  7  cases  in  which  the 
glands  are  stated  to  have  been  enlarged  at  time  of  operation,  and 
the  one  in  which  the  operation  was  incomplete,  we  have  remaining  26 
cases  where  the  anterior  triangle  was  cleaned  out,  in  whom  the  re- 
sults are  definitely  known,  and  in  whom  there  was  no  mouth  re- 
currence. Of  these  26  cases,  24  remained  well,  and  2  died  of  recurrence 
in  the  nodes  of  the  opposite  side.  Not  one  of  the  26  cases  died  of 
recurrence  in  the  side  of  the  neck  from  which  the  nodes  were  removed. 
Compare  this  with  the  22  selected  cases,  previously  cited,  in  which  the 
glands  were  not  removed,  but  in  none  of  which  were  they  palpable  at 
the  time  of  the  operation  on  the  tongue.  In  this  series  10  died  of 
recurrence  in  the  neck.  Although  to  say  that  glands  are  not  palpable 
when  the  neck  is  not  opened  does  not  say  they  were  not  enlarged,  still 
we  think  this  can  be  taken  as  fair  argument  for  the  removal  of  the 
glands  in  every  early  case.  Butlin  wrote,  in  a  very  recent  personal 
communication :  "It  seems  as  if  it  were  hard  lines  on  those  people  to 
induce  them  to  undergo  operation  which  may  not  be  necessary,  because 


576  SURGERY  OF  THE  MOUTH  AND  JAWS. 

half  of  them,  or  more,  would  suffer  from  glandular  disease  with- 
out the  operation.  But  the  trend  of  surgical  opinion  has  been  for 
many  years  in  favor  of  doing  too  much  rather  than  too  little  and  of 
removing  those  parts  and  structures  which  are  very  liable  to  become 
diseased,  although  there  is  no  certainty  that  they  will  become  diseased. 
Certainly,  I  would  have  my  glands  removed  if  I  had  cancer  of  the 
tongue."  Mikulicz  and  Kiimmel  believe  that  the  nodes  of  one  or  both 
sides  should  be  removed  in  every  instance,  except  when  the  growth  is 
located  upon  the  extreme  tip  of  the  tongue.  Just  why  the  exception 
is  made  in  the  latter  situation,  we  are  not  able  to  determine. 

(e)  Is  It  Necessary  to  Remove  Primary  Growth  and  the 
Lymphatic  Areas  in  One  Mass,  as  Is  Done  With  Carcinoma  oe 
THE  Breast? — Butlin  answers  this  question  in  the  negative.  He 
states  that  he  has  rarely  removed  the  primary  growth  and  the  lym- 
phatics in  one  continuous  mass ;  yet  in  only  two  of  his  cases  could  it  be 
reasonably  concluded  that  recurrence  was  due  to  afifection  of  the  tissues 
that  were  left  behind  between  the  primary  disease  and  the  glands. 
The  excision  of  the  tumor,  the  floor,  and  the  glands  in  one  mass  pre- 
cludes doing  a  two-step  operation,  which  latter  greatly  lessens  the 
operative  mortality.  It  is  only  in  his  "excision  at  the  root"  that  Kocher 
attacks  the  glands  and  primary  tumor  at  the  same  operation. 

(f)  To  What  Extent  Should  the  Lymph  Nodes  Be  Re- 
moved?— Whatever  operation  is  done  on  the  neck,  the  lymph  nodes, 
lymphatic  vessels,  and  the  tissues  that  carried  them  should  be  removed 
in  one  mass,  from  the  floor  of  the  mouth  down.  Although  there  are  a 
few  instances  where  recoveries  have  occurred  after  the  removal  of  single 
or  several  enlarged  nodes,  it  is  possible  that  in  these  instances  the 
enlargement  was  due  to  other  causes  than  infection  with  cancer.  There 
is  reason  to  believe  that  the  lymphatics  in  their  normal  condition  can, 
to  a  limited  extent,  destroy  cancer  cells,  as  they  do  other  infections,  but 
it  is  well  known  that  tissues  that  are  injured  by  trauma  are  less  re- 
sistant to  infections  than  are  those  that  are  healthy.  Even  if  all  of 
the  diseased  glands  could  be  removed  by  dissecting  them  out  indi- 
vidually, which  is  practically  a  surgical  impossibility,  still  this  would 
not  deal  with  the  cells  that  might  be  yet  within  the  lymph  ducts.  It  is 
conceded  that,  if  the  lymph  nodes  are  to  be  removed  for  any  disease, 
they  should  be  taken  out  en  masse  with  the  lymphatic  ducts  and  the 
tissue  that  supports  them.  If  the  removal  is  for  carcinoma,  even  more 
radical  removals  seem  to  be  productive  of  better  ultimate  results 
Butlin  is  content  in  most  cases,  at  least  those  supposedly  early  cases  in 
which  palpable  enlargement  of  the  lymph  nodes  has  not  occurred,  to 
remove  the  contents  of  the  anterior  triangle,  which  include  the  super- 
ficial and  deep,   submental  and  submaxillary  nodes,  the  submaxillary 


CANCER  OF  THE  TONGUE.  577 

salivary  gland,  the  lower  facial  nodes,  the  lower  parotid  nodes,  the 
deep  and  supferficial  cervical  nodes,  and  the  infrahyoid  nodes  that  lie 
near  the  omohyoid  muscle.  This  he  does  very  thoroughly.  This  is 
also  the  procedure  recommended  by  Kocher.  Of  late,  more  radical 
measures  have  been  advocated. 

Maitland  advocates  the  removal  of  the  sternomastoid  and  the  clear- 
ing out  of  both  the  anterior  and  posterior  triangles,  with  or  without 
the  removal  of  the  internal  jugular  vein,  as  circumstances  indicate. 

Crile  has  applied  the  methods  now  sanctioned  in  regard  to  carci- 
noma of  the  breast  and  removes  all  of  the  lymph  nodes,  the  internal 
jugular  vein,  and  the  sternomastoid  in  one  block.  In  fact,  he  has  shown 
that  all  structures  in  one  side  of  the  neck,  including  the  vagus  and 
hypoglossal  nerves,  with  the  exception  of  the  carotid  artery,  can  be 
removed  with  comparative  safety. 

(g)  Should  the  Lymph  Nodes  of  Both  Sides  oe  the  Neck 
Be  Removed? — If  the  carcinoma  is  bilateral,  or  situated  on  the  base, 
there  is  no  doubt  that  the  lymphatics  of  both  sides  should  be  removed. 
Although  it  occasionally  happens  that  early  infection  of  the  opposite 
lymphatics  results  from  a  laterally  situated  growth  of  the  body,  But- 
lin's  statistics  show  that  this  happens  so  seldom  as  to  hardly  warrant 
the  bilateral  excision  as  a  routine  procedure,  but  if  not  counterbal- 
anced by  the  increased  operative  risk,  it  would  save  some  patients.  In 
200  cases  of  Butlin's  the  lymph  nodes  were  palpably  affected  on  both 
sides  in  9  instances.  In  6  of  these  the  cancer  occupied  both  sides  of 
the  tongue.  In  3  of  the  200  cases,  the  nodes  of  the  opposite  side  were 
involved.  In  2  of  the  3  cases,  the  nodes  were  removed  from  the  neck 
on  the  opposite  side  of  the  primary  growth  only;  and  both  of  these  cases 
were  well  a  number  of  years  after  the  operation.  In  2  cases  the  nodes 
on  the  opposite  side  became  enlarged  after  an  otherwise  successful 
operation  on  the  tongue  and  one  side  of  the  neck.  If  the  lymphatic 
involvement  on  one  side  is  sufficiently  advanced  to  warrant  one  of  th<? 
more  radical  operations  that  includes  the  removal  of  the  internal  jugu- 
lar vein,  it  seems  to  us  that  under  these  circumstances  it  would  be  wise 
to  do  a  simpler  operation  on  the  other  side  within  a  few  days.  Daugel 
removed  both  internal  jugular  veins  in  one  patient,  at  one  operation, 
with  recovery;  but  this  is  a  result  that  cannot  be  expected  to  be 
repeated  often. 

(h)  Should  the  Primary  Tumor  and  the  Lymph  Nodes  Be 
Removed  at  the  Same  or  at  a  Separate  Operation? — In  22  of 
Butlin's  cases  in  which  the  lymph  nodes  and  the  primary  tumor  were 
removed  at  a  single  sitting,  there  were  4  operative  deaths.  In  47 
cases  in  which  the  lymph  nodes  were  removed  a  few  days  previous  to, 
or  a  few  days  after,  the  operation  on  the  tongue,  there  was  1  death 


578  SURGERY  OF  THE  MOUTH  AND  JAWS. 

due  to  operation,  which  gives  a  death  rate  of  18,18  per  cent  for  the 
single  operation,  and  2.12  per  cent  for  cases  that  were  operated  in  two 
stages. 

Butlin  gives  the  series  of  two-stage  operations  as  consisting  of  48 
cases  with  2  deaths,  but  explains  in  a  note  that  in  one  case  the  tongue 
was  reoperated  on  at  the  time  the  glands  were  removed,  for  fear,  the 
primary  operation  not  being  sufficiently  extensive,  the  entire  neck 
wound  might  become  septic.  This  cannot  be  considered  a  two-step 
operation  in  the  sense  that  we  here  take  it,  and  we  therefore  exclude 
this  case. 

Warren  suggests  that  the  two-step  operation  may  represent  but  a 
stage  in  the  development  of  the  surgery  of  carcinoma  of  the  mouth, 
and  that  later,  by  improved  methods,  a  continuous  operation  may  be 
performed  with  comparative  safety. 

If  we  grant  the  present  advisability  of  a  two-  or  three-step  opera- 
tion, we  are  brought  to  the  question : 

(i)  Shali.  the  Removal  of  the  Primary  Growth  or  the 
Lymphatics  Be  Done  First? — We  have  always  been  impressed  with 
the  idea  that  even  if  cancer-producing  cells  do  not  lodge  in  the  lymph 
ducts  they  must  require  some  time  for  their  passage  from  the  primary 
growth  to  the  nodes.  Therefore,  on  these  theoretical  grounds,  we 
believe  that,  if  the  glands,  intermediate  tissue,  and  primary  growth  are 
not  removed  in  one  mass,  the  removal  of  the  primary  growth  should 
precede  the  lymphatic  removal  by  some  days,  and  that  the  lymphatic 
operation  should  not  precede  the  removal  of  the  primary  growth. 
This  view  does  not  seem  to  be  shared  by  men  of  large  experience,  but 
we  have  lately  seen  one  case  where  the  neck  wound  became  extensively 
infected  with  carcinoma,  where  a  block  gland  dissection  was  made 
without  removal  of  a  cancer  in  the  mouth.  In  certain  instances,  there 
are  strong  reasons  for  doing  the  neck  operation  first.  After  active 
growth  has  once  started  within  the  lymph  nodes,  it  proceeds  at  a  much 
more  rapid  rate  than  the  cancer  of  the  tongue  or  lip,  and  it  is  believed 
under  these  conditions  to  be  good  surgery  to  do  the  glands  first,  if  the 
whole  operation  cannot  be  carried  out  at  one  sitting.  If  the  operation 
upon  the  tongue  includes  the  removal  of  the  lower  part  of  the  hyo- 
glossus  muscle,  then  the  mouth  cavity  will  be  opened  at  the  neck- 
operation,  which  increases  the  chance  of  infection  and  necessitates 
leaving  the  upper  part  of  the  neck  open  to  avoid  filling  the  wound  with 
food  and  mouth  secretions.  Another  argument  that  has  been  advanced 
for  a  primary  neck  operation  is  that,  if  the  mouth  operation  is  per- 
formed first,  the  neck  wound  is  liable  to  become  infected  through  the 
lymph  ducts.  If  the  mouth  wound  is  properly  cared  for,  this  will 
be  avoided,  and  it  seems  to  us  that  this  is  somewhat  of  an  acknowledg- 


CANCER  OF  THE  TONGUE.  579 

ment  of  our  first  contention.  If  the  neck  can  become  infected  with 
sepsis  from  the  mouth  wound,  why  not  from  carcinoma,  if  the  latter 
is  still  in  place?  Under  ordinary  circumstances  it  is  the  custom  of 
most  surgeons  who  advocate  a  two-step  operation  to  do  the  intraoral 
one  first.  Butlin  usually  operates  upon  the  glands  as  soon  as  the 
patient  begins  to  take  food  well  and  has  somewhat  recovered  from 
the  first  operation — about  ten  days. 

The  primary  removal  of  the  lymphatics  has  been  advocated  for  two 
other  reasons:  (1)  that  at  the  time  of  the  first  operation  the  lingual 
and  facial  arteries  can  be  conveniently  tied,  as  a  preliminary  to  the 
tongue  operation ;  (2)  that,  if  the  neck  is  operated  on  first,  the  patient  is 
less  likely  to  back  out  of  the  second  operation.  Although  a  pre- 
liminary ligation  of  the  lingual  artery  gives  an  almost  bloodless  oper- 
ation, was  advocated  by  Billroth  and  Treves,  and  is  still  utilized  by 
Kocher  and  other  surgeons  when  for  any  reason  the  first  operation 
is  done  upon  the  neck,  still  it  is  not  generally  considered  a  necessary 
routine  procedure;  and  in  the  operations  to  be  described,  hemorrhage 
is  always  controllable.  The  second  point  is  of  some  value,  as  it  not 
infrequently  happens  that  a  patient  who  has  no  evident  disease  in  the 
neck  becomes  unwilling  to  undergo  a  second  operation  after  having 
experienced  the  first.  Butlin  meets  this  difficulty  by  not  stating  that 
there  will  be  two  operations,  but  informs  the  friends  that  he  will  begin 
the  operation  on  such  a  day  and  finish  it  nine  or  ten  days  later. 

(j)  Should  Excision  of  thi;  Tongue  Be  Preceded  by  Laryn- 
GoTOMY? — At  present  most  operators  seem  to  prefer  depending  on  the 
position  of  the  patient  to  prevent  the  aspiration  of  blood  during  the 
operation — Kocher  is  among  these.  Crile  uses  his  nasal  anesthesia 
tubes  with  packing  of  the  pharynx,  but  this  procedure  is  hardly  appli- 
cable if  the  excision  is  to  extend  behind  the  attachment  of  the  anterior 
faucial  pillar.  Whitehead  advocated  preliminary  laryngotomy  as  a 
routine  procedure,  and  Butlin,  since  1900,  has  made  it  his  routine 
practice.  The  Trendelenburg  expanding  cannula  is  not  popular.  It 
is  one  of  the  things  that  is  not  apt  to  be  on  hand  when  desired,  and  apt 
to  be  out  of  order  if  on  hand.  Besides,  it  may  cause  reflex  nerve 
irritation  when  in  place,  or  be  followed  by  local  injury  of  the  tracheal 
mucous  membrane.  A  simple  laryngeal  tube  can  be  quickly  inserted, 
and  after  spraying  with  a  5  per  cent  novocain  solution,  the  pharynx 
can  be  packed  with  gauze.  If  the  tracheal  tube  is  arranged  so  that  a 
rubber  tube  can  be  attached  to  its  external  opening,  a  gas-oxygen 
anesthesia  may  be  given,  which  is  a  great  advantage  here.  Final 
judgment  has  not  been  passed  upon  tracheal  insufflation,  but  it  is  pos- 
sible that  it  may  supplant  all  other  methods. 


580  SURGERY  OF  THE  MOUTH  AND  JAWS. 

OPERATION  FOR  THE  REMOVAL  OF  THE  TONGUE. 

While  in  the  preserxce  of  mahgnant  disease,  time  is  precious,  and 
the  operation  should  be  done  as  soon  as  possible ;  still  some  local  or 
general  preparation  may  be  indicated,  the  carrying  out  of  which  will 
materially  lessen  the  operative  risk. 

Local  Preparation. — It  is  not  always  possible  to  get  the  mouth 
in  very  good  condition,  because  the  local  tenderness  may  preclude 
extensive  manipulations  and  it  is  not  desirable  to  give  a  general  anes- 
thetic for  this  purpose.  The  teeth  should  be  cleansed  thoroughly 
several  times  a  day — if  possible,  with  a  brush.  If  in  bad  condition, 
the  tartar  might  be  scraped  off,  loose  and  carious  teeth  removed,  and 
pus-pockets  treated  with  tincture  of  iodin. 

Butlin  recommends  that  when  possible  the  mouth  should  be  re- 
peatedly wiped  out,  especially  the  pockets,  with  soft  pledgets  of  cotton 
wool  or  bits  of  marine  sponge  soaked  in  a  bicyanid  or  bichlorid  of 
mercury  solution,  1 :1000.  Also,  over  the  vascular  granulations,  the 
same  solution  may  be  painted  with  a  camel's  hair  brush,  but  if  the 
growth  is  covered  with  hard  nodular  epithelium,  it  will  do  no  harm  to 
rub  it  with  a  soft  sponge  and  clear  all  the  fur  and  debris  out  of  the  sulci. 
In  doing  this,  no  free  fluid  should  be  allowed  to  run  into  the  mouth, 
and  the  patient  should  rinse  the  mouth  immediately  afterward.  The 
mouth  should  be  rinsed  frequently  with  a  V2  per  cent  solution  of  po- 
tassium permanganate,  especially  after  eating.  Very  foul  sloughy 
surfaces  may  be  cocainized  and  then  painted  with  a  10  per  cent  solution 
of  formalin  or  rubbed  with  lunar  caustic.  The  nasal  passages  and 
nasopharynx  may  be  douched  with  alkaline  antiseptic  solution  (N.  F.), 
one  to  three  of  water,  and'Kocher  recommends  that  suppurating  crypts 
in  the  tonsils  should  be  cleaned  out.  These  local  preparations  cer- 
tainly lessen  the  liability  to  sepsis  and  should  be  carried  out  as  com- 
pletely as  practicable.  The  oozing  of  blood  from  the  growth  may  be 
controlled  by  some  chemical  styptic,  the  cautery  at  a  very  dull-red 
heat,  or  by  ligating  the  lingual  artery. 

Some  operators  precede  a  lingual  amputation,  and  in  fact  any 
serious  mouth  operation,  by  a  preliminary  injection  of  polyvalent 
streptococcus  antitoxin.  We  do  not  believe  that  anyone  can  as  yet 
show  a  series  of  cases  sufficiently  large  to  serve  as  a  basis  for  con- 
clusions. 

General  Preparation. — Many  patients  with  very  early  growths 
need  no  special  general  preparation.  Those  who  are  weak  from  pain, 
loss  of  sleep,  lack  of  food,  and  from  hemorrhage  may  be  improved  by 
a  few  days  of  special  treatment,  possibly  a  blood  transfusion  in  extreme 
cases  of  debility. 


CANCER  OF  THE  TONGUE.  581 

Position  on  the  Table. — The  semisitting  position,  recommended 
by  Whitehead,  gives  the  best  view,  and  if  the  patient  is  not  too  deeply 
anesthetized,  this  will  not  be  accompanied  by  the  aspiration  of  blood. 
The  Trendelenburg  position  is  supposed  to  guard  against  aspiration, 
but  it  has  not  always  served  us  well  in  mouth  operations.  Butlin 
states  that  formerly  he  used  the  Whitehead  position,  but  now  always 
places  the  patient  on  his  side.  "The  patient  is  placed  upon  his  side 
with  his  head  a  little  forward  and  downward,  so  that  the  blood  runs 
naturally  into  the  cheek  and  out  of  the  mouth."  If  the  table  is  made 
to  slope  a  little  downward,  toward  the  head-end,  the  advantages  of 
the  Trendelenburg  and  lateral  positions  are  combined.  This  we  have 
found  very  serviceable. 

Anesthetic. — A  general  anesthetic  should  be  used,  and  we 
almost  invariably  use  ether,  unless  it  be  oxygen  and  nitrous  oxid, 
which  may  be  conveniently  administered  through  the  laryngotomy  tube 
or  Crile's  nasal  tubes.  The  latter  are  only  of  service  when  the  oper- 
ation is  confined  to  the  anterior  part  of  the  tongue. 

INTRAORAL  OPERATION. 

In  the  more  extensive  of  the  intraoral  lingual  operations,  especially 
those  that  extend  to  or  through  the  faucial  pillars,  the  work  is  much 
facilitated  by  splitting  the  cheek  straight  back  from  the  corner  of  the 
mouth  to  the  anterior  border  of  the  masseter  muscle.  This  incision 
passes  below  the  parotid  duct  and  above  the  mandibular  division  of  the 
seventh  nerve,  and  when  properly  repaired,  gives  a  scarcely  noticeable 
deformity.  This  was  first  advocated  by  Roser,  is  sometimes  used  by 
Butlin,  and  strongly  recommended  by  Kocher. 

V-SHAPED  OPERATION. 

Small  tumors  situated  on  the  anterior  fourth  or  third,  or  on  the 
lateral  border,  of  the  tongue  may  be  removed  by  a  V-shaped  excision. 
Unless  these  tumors  are  seen  very  early  and  confined  to  near  the  tip, 
this  is  not  applicable  to  carcinoma,  in  which  the  excision  should  be  at 
least  1^  centimeters  from  the  border  of  the  growth.  Even  in  very 
early  carcinomata,  it  should  not  be  employed  when  the  microscopical 
examination  shows  it  to  be  very  malignant.  The  V-shaped  excision  is 
made  as  follows : 

The  tongue  is  drawn  forward  with  vulsellum  forceps,  one  pair  on 
each  side  of  the  growth.  For  a  lateral  growth  the  cheek  is  retracted 
or  split.  The  proposed  incision  is  first  outlined  on  the  dorsum.  Two 
or  three  through-and-through  silkworm  gut  sutures  are  placed  by  per- 
forating the  tongue  on  each  side  5  millimeters  beyond  the  line  of  the 
proposed  incision,  in  such  a  way  that  when  the  incision  is  made  the 


583 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


remaining  raw  surfaces  can  be  immediately  approximated  by  tying 
these  sutures.  Each  suture  is  entered  at  the  dorsum,  to  one  side 
of  the  proposed  excision,  and  passes  directly  through  the  substance 
of  the  tongue  without  deviating  toward  the  plane  of  excision.  The 
same  needle  next  penetrates  from  the  sublingual  to  the  dorsal  surface 
at  a  corresponding  point  on  the  other  side  of  the  growth.  After  the 
through-and-through  sutures  are  placed  in  this  way,  the  free  ends 
will  protrude  from  the  dorsum,  and  at  least  5  centimeters  of  each  loop 
from  the  under  surface.     The  tongue  still  being  held  by  the  vulsellum 


Fig.  409.  V-shaped  excision  from  tlie  tongue.  The  sutures  are  placed  previous  to 
making  the  excision,  and  hemorrhage  is  controlled  by  immediately  approximating  the 
borders. 


forceps,  its  substance  is  grasped  on  each  side,  external  to  the  line  of  the 
incision,  with  a  long  narrow-bladed  forceps.  These  should  be  placed 
over  the  sutures  so  as  not  to  come  quite  up  to  the  line  of  incision ;  other- 
wise the  tongue,  as  it  is  cut,  will  slip  from  between  the  forceps  blades. 
The  forceps  are  not  locked,  but  are  held  tight  by  an  assistant.  The 
teeth  on  the  points  of  Kocher's  straight  forceps  prevent  slipping  just 
where  the  blades  will  be  most  separated.  These  preparations  having 
been  made,  the  surgeon  takes  the  two  vulsellum  forceps  in  one  hand 
and  with  a  very  sharp  knife  or  sharp,  strong  scissors  makes  the  two 


CANCER  OF  THE  TONGUE. 


583 


incisions.  The  forceps  are  released,  and  the  silkworm  gut  sutures  tied 
to  control  the  bleeding.  Some  supplementary  sutures  may  be  added 
where  needed  (Fig.  409). 

EXCISION  OF  ONE  HALF  OF  THE  BODY. 

The  tongue  is  grasped  on  each  side  near  the  tip  with  vulsellum 
forceps  or  retention  sutures,  the  patient  being  turned  to  the  side  oppo- 
site the  growth.  One  retention  suture  or  forceps  is  held  by  the  oper- 
ator, and  the  other  by  an  assistant.  The  tongue  is  drawn  out,  and  the 
dorsal  mucous  membrane  split  exactly  in  the  midline  from  well  behind 


Fig.  410.  Removal  of  one  half  of  the  tongue,  anterior  pillar,  and  tonsil  from 
within  the  mouth,  after  splitting  the  cheek  and  also  dividing  the  tongue  in  the  midline, 
and  the  mucous  membrane  of  the  floor.  Tongue  in  position  for  cutting  the  geniohyo- 
glossus  muscle  from  the  jaw. 

the  disease  to  near  the  tip ;  then,  elevating  the  tip  somewhat,  the  body 
is  divided  exactly  in  the  midline  as  far  back  as  the  attachment  of  the 
frenum  with  one  clip  of  a  pair  of  strong,  sharp  scissors.  The  re- 
maining part  of  the  body  is  best  split  by  Butlin's  plan  of  using  the 
fingers  of  both  hands,  making  the  division  exactly  in  the  midline.  If 
the  plane  of  the  tear  deviates  from  median,  the  lingual  artery  might 
be  injured.  The  halves  of  the  tongue  are  to  be  separated  as  far  back 
as  the  proposed  excision,  forward  to  the  mandible  and  downward  to 
the  inferior  borders  of  the  geniohyoglossi  muscles.  After  separating 
the  two  geniohyoglossi  muscles,  all  facial  tissues  should  be  removed 


584 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


from  the  surface  of  the  heahhy  muscle.  In  this  way  the  lymph  nodes 
will  be  included  in  the  excision.  If  the  growth  approaches  near  the 
midline,  it  is  safer  to  make  the  division  just  to  the  other  side  of  the 
midplane,  so  as  to  include  the  median  septum  with  the  part  to  be 
excised.  This  is  not  quite  so  easy  as  splitting  the  tongue  in  the  median 
plane,  and  to  avoid  the  possibility  of  troublesome  hemorrhage,  it  would 
be  safer  to  have  a  provisional  ligature  around  the  lingual  artery  of  the 
unaffected  side  in  the  digastric  triangle.  This  ligature  should  be 
placed  distal  to  the  dorsal  branch.  After  splitting  the  tongue  lateral 
of  the   midline,   some   fibers  of  the   geniohyoglossus  muscle  of  that 


Fig.  411.  The  tongue  in  position  for  cutting  it  across  its  base.  In  order  to  illus- 
trate its  position,  the  lingual  artery  is  shown  very  much  more  plainly  than  it  can  be 
made  to  appear  at  operation. 

side  will  have  to  be  cut.  The  tongue  having  been  split,  the  mucous 
membrane  is  incised  in  the  floor  at  the  side  of  the  tongue.  If  the  carci- 
noma involves  the  floor,  it  may  have  to  be  treated  as  will  be  presently 
described.  If  not,  the  incision  in  the  mucosa  should  be  at  least  1  cen- 
timeter from  the  edge  of  the  growth.  The  lateral  incision  extends  as 
far  back  as  is  needed  and  forward  to  the  frenum.  If  possible,  the 
anterior  part  of  the  lateral  incision  should  be  behind  the  opening  of  the 
submaxillary  duct.  With  the  finger  the  mucosa  is  pushed  from  the 
subjacent  tissues  toward  the  tongue,  and  the  latter  is  freed  from  the 
adjoining  structures  of  the  floor  until  the  outer  surface  of  the  genio- 


CANCER  OF  THE  TONGUE. 


585 


hyoglossus  is  freed  as  far  forward  as  its  origin  from  the  genial  tubercles 
at  the  symphysis.  In  doing  this,  the  lingual  vein  may  be  cut  or  torn, 
and  the  lingual  nerve  will  be  divided.  If  the  cancer  extends  to  the 
floor  of  the  mouth,  but  does  not  involve  the  bone  or  the  mylohyoid 
muscle,  then  the  structures  in  the  floor  should  be  included  with  the 
excised  part  of  the  tongue.  To  do  this,  the  incision  through  the  mu- 
cous membrane  is  made  close  to  the  inner  border  of  the  jaw.  The 
structures  in  the  floor,  the  intraoral  part  of  the  submaxillary  gland 
and  its  duct,  the  sublingual  gland,  and  the  lingual  vein  and  nerve  are 
elevated  from  the  mylohyoid  muscle  with  the  finger,  until  the  outer 
border  of  the  geniohyoid  muscle  is  exposed. 

This  having  been  accomplished,  the  excision  of  the  tongue  pro- 
ceeds. The  diseased  half  of  the  tongue  is  drawn  upward,  making  the 
geniohyoglossus  tense,  which  muscle  is  cut  with  scissors  close  to  the 
genial  tubercle   (Fig.  410).     If  the  entire  half  is  to  be  removed,  the 


Dorsal  artery. 
Styloglossus  muscle. 

Hyoglossus  muscle. 

Geniohyoglossus  muscle. 

Geniohyoid  muscle. 

Digastric  muscle., 


Masseter  muscle. 

Jaw-bone. 

Facial  artery. 

Lingual  artery. 

Submaxillary  gland. 
Mylohyoid  muscle. 

Platysma  muscle. 


Fig.  412.      Diagrammatic  coronal  section  of  the  tongue. — After  Butliu. 


anterior  pillar  of  the  fauces  must  be  cut  through.  Before  beginning 
the  transverse  incision,  the  affected  half  of  the  tongue  should  have 
been  so  freed  from  the  floor  of  the  mouth  and  fauces  that  it  can 
be  drawn  well  out  into  view  beyond  the  line  of  the  teeth,  and  this 
should  take  place  without  any  blood  vessels  of  importance  having  been 
injured  (Fig.  411).  The  transverse  cut  is  made  wnth  short  cuts  with 
the  scissors  through  the  muscles  attached  to  the  base,  at  least  2  centi- 
meters beyond  the  growth.  The  cutting  is  done  from  the  lower 
toward  the  dorsal  surface.  The  lingual  artery  can  usually  be  secured 
before-  it  is  cut.  It  lies  near  the  midline  and  appears  as  a  white  cord 
in  the  midst  of  the  muscles.  The  exact  position  of  the  artery  is  to 
the  outer  side  of  the  insertion  of  the  geniohyoglossus  muscle.  Near 
the  hyoid  bone  it  is  covered  by  the  hyoglossus  muscle,  but  anteriorly 
it  lies  deep  in  the  sulcus  between  the  geniohyoglossus  and  the  inner 
border  of  the  inferior  lingualis  muscle.  It  should  be  approached  with 
shallow  cuts,  feeling  carefully  for  its  pulsations.     As  soon  as  these 


586 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


are  recognized,  a  pair  of  sharp-pointed  artery  forceps,  with  blades 
partly  spread,  are  thrust  into  the  muscle,  and  the  vessel  clamped ;  while 
doing  this,  the  tongue  is  steadied  by  placing  the  index  finger  of  the 
left  hand  upon  the  pharyngeal  surface.  The  artery  should  be  imme- 
diately tied. 

After  the  lingual  artery  is  controlled,  the  tongue  can  be  then  cut 
away  quickly,  the  dorsal  artery  being  caught  after  being  cut  at  the 
outer  border  (Fig.  413).  If  the  structures  in  the  floor  of  the  mouth 
have  been  included  in  the  excision,  these  must  be  cut  across  posteriorly, 


Fig.  413.  Removal  of  one  half  of  the  tongue,  the  anterior  pillar,  and  tonsil,  com- 
pleted. In  order  to  display  the  posterior  part  of  the  space,  the  remaining  part  of  the 
tongue  is  represented  too  far  to  the  side. 


and  the  bleeding  points  caught  individually  with  pointed  forceps.  The 
cut  end  of  the  intraglandular  excretory  duct  of  the  submaxillary  must 
not  be  ligated  (Fig.  413).  Another  plan  of  controlling  hemorrhage  is 
to  place  a  row  of  through-and-through,  interlocking,  mattress  sutures 
across  the  base  of  the  tongue.  This  line  of  sutures  must  be  well  be- 
hind the  transverse  cut,  otherwise  one  of  them  might  be  clipped  during 
the  excision.  This  takes  time,  and  sometimes  forceps  and  sutures  slip 
If  the  cancer  has  involved  the  faucial  pillar  or  tonsil,  the  pillars, 
tonsil,  and  half  of  the  velum  can  be  removed  with  the  tongue  through 
the  mouth  after  splitting  the  cheek  (see  Excision  of  Tonsil,  page  024). 


CANCER  OF  THE  TONGUE.  587 

After  completing  a  unilateral  excision,  some  surgeons  prefer  to  double 
the  half  tongue  back  on  itself,  placing  the  tip  posteriorly  and  suturing 
the  apposed  raw  surfaces.     This  makes  a  short,  broad  stump. 

BILATERAL  EXCISION. 

The  tongue  is  secured  by  the  two  stout  ligatures  or  vulsellum  for- 
ceps, as  in  the  excision  of  one  half  of  the  body.  The  mucous  mem- 
brane of  the  floor  of  the  mouth  is  treated  in  the  same  manner,  but  on 
both  sides.  The  anterior  pillars  are  divided  if  the  disease  extends  far 
back.  The  tongue  is  raised  up  so  that  the  geniohyoid  muscles  are 
made  tense,  and  they  are  cut  across  with  scissors  close  to  the  genial 
tubercles.  The  entire  tongue  is  then  separated  as  far  back  as  the  epi- 
glottis, or  if  the  disease  is  not  very  far  back,  to  a  point  2  centimeters 
behind  the  evident  disease.  In  this  operation  both  geniohyoglossi  mus- 
cles are  divided  at  the  genial  tubercles,  but  the  geniohyoid  should  not 
be  injured  if  they  are  not  apt  to  be  included. 

The  transverse  cut  is  made  as  in  excision  of  one  half  of  the  body, 
but  both  arteries  being  controlled.  Just  before  the  tongue  is  sep- 
arated, a  ligature  is  passed  through  the  tissues  of  the  stump,  through 
the  glossoepiglottic  fold,  if  the  entire  tongue  is  removed — so  that 
it  can  be  drawn  forward  in  case  of  hemorrhage.  This  ligature  serves 
not  only  in  cases  of  hemorrhage,  but  also  to  draw  the  stump  forward 
in  case  of  dyspnea.  It  may  generally  be  removed  with  safety  on  the 
day  following  the  operation. 

The  operation  as  described  is  the  operation  of  Whitehead,  which 
Butlin  prefers  to  any  other  for  the  removal  of  the  tongue  within  the 
mouth.  Instead  of  removing  the  tongue  in  one  piece,  however,  he 
generally  splits  it,  and  removes  it  in  two  halves. 

If  the  vessels  are  cut  before  being  caught,  hemorrhage  is  free.  The 
stream  from  the  larger  vessels  is  out  of  the  mouth,  and  they  can  be 
secured  in  a  moment.  The  vessels  should  be  tied  as  soon  as  caught. 
Clamps  are  apt  to  become  loosened  and  fall  off,  or  tear  away  from  the 
soft  tissues.  And  it  must  be  borne  in  mind  that  it  is  by  no  means 
uncommon  for  a  patient  to  come  partly  out  of  the  anesthesia  during 
the  operation. 

If  in  a  complete  amputation  the  tongue  should  be  separated  be- 
fore the  larger  vessels  are  ligated — an  awkward  accident,  which  ought 
not  to  occur — Mr,  Butlin  suggests  that  Mr.  Christopher  Heath's  recom- 
mendation must  be  borne  in  mind :  The  stump  is  drawn  forcibly 
forward  by  the  forefinger  hooked  around  it,  and  the  bleeding  is  thus 
temporarily  arrested.  When  the  blood  has  been  sponged  out  of  the 
mouth,  the  vessels  can  be  taken  up  and  tied. 

In  his  "normal  excision"  of  the  tongue  by  splitting  the  lower  jaw 


588  SURGERY  OF  THE  MOUTH  AND  JAWS. 

and  floor  of  the  mouth,  Kocher  calls  attention  to  the  value  of  drainage 
placed  through  th^  floor  of  the  mouth  just  in  front  of  the  stump. 
This  can  be  placed  after  an  intraoral  excision  through  a  stab  wound 
through  the  skin  and  mylohyoid  muscle  in  front  of  the  hyoid  bone,  the 
rubber  drain  entering  the  mouth  between  or  to  the  side  of  the  genio- 
hyoid muscles.  The  drain  removes  a  quantity  of  saliva  and  wound 
secretion,  and  we  believe  adds  greatly  to  the  comfort  and  safety  of  the 
patient.  With  such  a  drainage  in  place,  it  is  proper  and  expedient, 
where  possible,  to  suture  the  mucous  membrane  over  most  of  the  raw 
surface  left  in  the  floor  of  the  mouth. 

Kocher  uses  the  actual  cautery  to  divide  the  mucous  membrane  in 
the  posterior  part  of  the  mouth  and  also  to  divide  the  muscles.  This 
is  done  both  to  limit  hemorrhage  and  to  limit,  infection  of  the  freshly 
cut  surface. 

Kocher's  "Normal  Excision." — This  consists  in  dividing  the  jaw 
in  the  middle  line  in  all  cases  where  the  cancer  extends  as  far  back  as 
the  isthmus  of  the  fauces,  and  where  it  has  involved  the  arch  of  the 
palate,  the  walls  of  the  pharynx,  and  the  soft  palate.  This  is  a  modi- 
fication of  Roux  and  Sedillot's  method.  It  causes  little  bleeding  and 
gives  sufficient  room  for  removal  of  pharyngeal  cancer  in  the  region 
of  the  isthmus  of  the  fauces.  An  incision  is  made  down  to  the  bone 
in  the  middle  line  through  the  lower  lip,  and  extending  as  far  as 
the  hyoid  bone.  The  submental  lymph,  nodes  are  removed.  The 
jaw-bone  is  sawed  through  just  to  one  side  of  the  symphysis — to  the 
side  on  which  the  tumor  is  situated.  The  cut  is  made  between  the 
central  and  lateral  incisor,  and  does  not  disturb  the  attachment  of 
the  muscles  to  the  genial  tubercles.  Previous  to  sawing  the  bone, 
without  removing  the  periosteum,  holes  are  drilled  on  each  side  of 
the  line  of  the  proposed  saw-cut.  These  are  for  the  wire  that  will 
hold  the  sawed  ends  in  apposition  after  the  operation,  and  should  at 
once  be  marked  by  placing  a  tack  or  a  piece  of  wire  in  each  of  them. 
The  two  halves  of  the  jaw  are  forcefully  separated  with  hooks.  The 
mylohyoid  muscle  is  split  near  the  midline,  the  digastrics  are  separated, 
and  the  outer  surface  of  the  geniohyoid  and  geniohyoglossus  is  exposed. 
The  excision  is  then  carried  out  in  a  manner  similar  to  that  already 
described.  The  nerves  and  muscles  are  preserved  as  much  as  possible, 
in  order  not  to  interfere  with  the  mechanism  of  swallowing  more  than 
is  necessary. 

Kocher  rubs  xeroform  into  the  cut  surfaces,  but  only  in  a  thin 
layer  so  as  not  to  produce  toxic  symptoms  if  swallowed.  The  two 
halves  of  the  jaws  are  then  approximated  with  strong  silver  wire,  and 
the  edges  of  the  jaw  firmly  united.  An  opening  is  left  a  little  above 
the  hyoid  bone  at  the  posterior  end  of  the  incision,  into  which  a  strip 


CANCER  OF  THE  TONGUE.  589 

of  xeroform  gauze  is  inserted.  We  prefer  rubber  dam  for  drainage 
when  it  is  not  expected  to  control  bleeding.  Kocher  believes  that  this 
operation  gives  the  best  access  and  causes  the  minimum  of  injury.  For 
reasons  already  given,  we  prefer  the  intraoral  excision  wherever  appli- 
cable. 

The  after-treatment  consists  in  the  free  application  of  iodoform, 
colloidal  silver,  or  xeroform,  while  the  wotind  is  kept  open  and  packed ; 
if  necessary,  the  packing-  is  removed  to  feed  the  patient  through  a  tube. 

Cancer  situated  between  the  faucial  isthmus  and  the  hyoid  bone  may 
be  attacked  by  a  suprahyoid  pharyngotomy,  preceded  by  a  laryngotomy, 
by  a  Mikulicz  high  lateral  pharyngotomy,  or  by  Kocher's  normal 
excision  just  described.  In  this  case,  not  only  is  the  jaw  split  in  the 
middle  line,  but  also  the  hyoid  bone  to  the  thyrohyoid  membrane,  pre- 
serving the  mucous  membrane  of  the  floor  of  the  mouth  as  far  as  the 
condition  of  the  growth  will  allow ;  and  then,  after  slitting  the  tongue 
and  holding  the  two  halves  apart,  one  can  decide  how  far  the  operation 
must  extend  in  order  to  remove  the  disease  completely. 

RESECTION  OF  THE  TONGUE  AT  THE  ROOT. 
KOCHER'S  OPERATION. 

For  a  complete  removal  of  the  tongue,  Kocher  recommends  this 
operation  for  the  following  reasons:  "(1)  because  it  gives  the  best 
access;  (2)  because  it  permits  of  the  simultaneous  removal  of  the 
glands  as  well  as  of  all  the  tissue  which  intervenes  between  them  and  ihe 
primary  seat  of  the  disease;  (3)  because  it  admits  of  preliminary 
ligature  of  the  lingual  or  external  carotid  arteries;  and  (4)  because 
it  allows  at  least  the  anterior  attachments  of  the  muscles  of  the  floor 
of  the  mouth  to  be  preserved." 

It  seems  to  us  that  from  the  figures  already  quoted  there  is  no 
advantage  from  the  simultaneous  removal  of  the  lymph  nodes  and  the 
primary  tumor,  but  rather  the  reverse.  The  advantage  of  primary 
ligation  of  the  lingual  artery  is  not  great. 

The  incision  begins  below  the  mastoid  process  and  extends  along 
the  anterior  border  of  the  sternomastoid,  and  then  forward  along  the 
crease  between  the  floor  of  the  mouth  and  the  neck  to  the  middle  line, 
and  lastly,  upward  to  the  lower  border  of  the  jaw.  In  cases  where 
the  extent  of  the  carcinoma  is  limited,  it  need  only  correspond  to  the 
middle  two  thirds  of  this  incision — i.  e.,  from  the  sternomastoid  as  far 
as  the  hyoid  bone.  After  the  subcutaneous  vessels  have  been  ligated, 
the  flap  is  dissected  up  and  fixed  with  a  suture  to  the  cheek.  Next, 
the  submaxillary,  submental,  and  upper  deep  cervical  lymphatics,  with  the 
submaxillary  salivary  gland,  are  dissected  free  from  the  great  vessels 
and  the  digastric  and  mylohyoid  muscles,  and  freed  from  their  connec- 


590  SURGERY  OF  THE  MOUTH  AND  JAWS. 

tions  on  the  outer  surface  of  the  jaw,  during  which  procedure  the 
facial  artery  and  vein  again  must  be  ligated. 

The  lingual  artery  is  easily  exposed  and  ligated  by  dividing  the 
fibers  of  the  hyoglossus  muscle  a  little  above  the  posterior  part  of  the 
greater  cornu  of  the  hyoid  bone.  The  hypoglossal  nerve  and  lingual 
vein,  which  lie  upon  the  outer  surface  of  the  muscle,  are  to  be  pre- 
served. 

The  outer  surface  of  the  mylohyoid  muscle  is  now  exposed  with  its 
nerve  lying  on  it.  This  muscle  is  divided  parallel  with  the  jaw  when 
the  mucous  membrane  is  felt.  After  the  limits  of  the  new  growth 
have  been  investigated,  the  mucous  membrane  is  incised  from  the  mouth, 
guided  by  the  finger.  From  this  opening  the  mucous  membrane  is 
further  divided  beyond  the  tumor,  artery  forceps  being  applied  to  the 
more  important  bleeding  vessels  of  the  mucous  membrane.  Further 
hemorrhage  is  readily  arrested  by  dragging  forward  the  soft  parts  by 
means  of  the  finger  introduced  through  the  wound  in  the  mouth. 

The  anterior  and  posterior  limits  of  the  tumor  are  defined,  as  well 
as  the  extent  to  which  the  jaw  is  involved.  If  the  jaw  is  involved, 
a  section  of  the  bone  is  removed. 

The  tongue  is  detached  from  the  hyoid  bone,  and  the  excision  com- 
pleted as  indicated  by  the  extent  of  the  disease,  any  hemorrhage  being 
readily  and  securely  arrested.  The  tongue  can  be  well  drawn  out 
through  the  floor  of  the  mouth  as  soon  as  the  mucous  membrane  has 
been  divided. 

If,  in  order  to  facilitate  the  administration  of  the  anesthetic,  a  pre- 
liminary tracheotomy  has  been  performed,  the  entrance  to  the  larynx 
is  at  once  plugged  with  sterilized  gauze  introduced  through  the 
pharynx. 

AFTER-TREATMENT. 

Kocher  recommends,  where  laryngotomy  has  been  done,  leaving 
the  wound  open  so  that  the  entrance  to  the  larynx  may  be  plugged 
with  sterilized  moist  (salt  solution)  gauze,  which  is  to  be  frequently 
changed — a  carbolic  or  sublimate  gauze  dressing  being  applied  over 
the  wound,  and  the  patient  fed  with  a  tube  each  time  the  wound  is 
dressed. 

We  have  not  been  successful  in  attempts  to  plug  the  opening  of 
the  larynx  under  the  circumstances  referred  to  above,  either  with  gauze 
or  plugs  of  cork  especially  formed  for  the  purpose.  The  slimy  mucus, 
which  seems  always  to  be  present  as  a  result  of  the  irritations  incident 
to  the  operation,  acts  as  a  lubricant,  and  the  plug  has  always  been 
coughed  out. 

As  long  as  swallowing  is  much  interfered  with,  the  patient  must 
remain  in  the  sloped  position,  with  head  and  neck  dependent. 


CANCER  OF  THE  TONGUE.  591 

After  drying-  the  surface  of  the  wound,  Whitehead  swabs  it  over 
with  a  varnish,  made  by  substituting  for  the  alcohol  ordinarily  used 
in  the  preparation  of  Friar's  balsam,  a  saturated  solution  of  iodoform, 
dissolved  in  nine  parts  of  ether  and  one  of  turpentine.  Butlin  uses 
powdered  iodoform,  or  packs  the  surface  of  the  wound  with  strips  of 
the  softest  iodoform  gauze,  which,  like  the  iodoform  varnish,  has  the 
effect  of  rapidly  stilling  the  oozing  of  blood.  Kocher  uses  xeroform, 
while  we  not  infrequently  have  used  a  15  per  cent  solution  of  colloidal 
silver,  both  as  a  paint  and  on  the  strips.  For  the  later  dressings,  we 
soak  iodoform  gauze  in  Friar's  balsam. 

For  troublesome  oozing,  where  there  is  no  vessel  which  can  be  tied 
with  advantage,  the  oozing  surface  is  covered  with  a  pad  of  gauze, 
which  is  fixed  in  place  by  means  of  one  or  more  silk  sutures.  If  no 
drain  has  been  led  out  from  the  floor  of  the  mouth  through  the  sub- 
maxillary region,  the  patient  is  put  to  bed,  lying  on  one  side,  with  the 
head  low,  so  that  all  the  mucus  escapes  by  the  angle  of  the  mouth  on 
to  a  piece  of  wool  and  gauze  or  a  folded  rough  towel.  If  the  patient 
lies  in  this  position,  there  is  little  difficulty  in  keeping  the  mouth  free 
from  the  collection  of  discharge,  mucus,  and  saliva.  If  the  discharges 
cling  to  the  interior  of  the  mouth,  and  the  patient  is  not  able  to  get  rid 
of  them,  the  nurse  wipes  them  out,  or  irrigates  the  mouth  frequently 
with  a  weak  antiseptic  solution.  If  a  good,  free,  external  drain  has 
been  placed  through  the  floor  of  the  mouth,  the  patient  may  sit  up 
as  soon  as  he  comes  out  from  under  the  anesthetic.  It  is  good  practice 
to  allow  the  patient  to  keep  small  pieces  of  ice  in  the  mouth  during  the 
first  day  or  two,  and  if  the  pain  is  severe,  morphin  should  be  given 
hypodermatically.  During  the  first  twenty-four  hours,  food,  if  neces- 
sary, is  administered  by  means  of  nutrient  enemata  or  a  carefully 
passed  stomach  tube. 

As  a  rule,  the  patient  can  swallow  on  the  second  day,  taking  food 
from  a  feeder  with  a  piece  of  India-rubber  tubing  on  the  spout.  He 
sits  up  or  lies  on  the  sound  side,  and  if  only  half  of  the  tongue  has  been 
removed,  places  the  tubing  on  the  sound  side  of  the  tongue.  In  cases 
in  which  the  operation  has  been  very  extensive,  it  may  be  necessary  to 
feed  through  a  tube  and  funnel.  A  soft  catheter,  about  No.  6  or  7 
English,  may  be  used  for  the  purpose.  It  is  fastened  to  a  long  piece 
of  India-rubber  tubing,  to  the  other  end  of  which  is  fixed  a  glass 
funnel.  The  catheter  is  smeared  with  oil  or  glycerin  and  is  introduced 
through  the  mouth  or  nose.  The  catheter  need  not  be  passed  more 
than  half  way  down  the  esophagus.  This  feeding  may  be  performed 
twice  or  three  times  in  twenty-four  hours,  a  pint  or  a  pint  and  a  half 
being  administered  on  each  occasion.  After  nutriment  enters  the 
esophagus,  Butlin  recommends  letting  a  little  water  run  in  to  clear 


592  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  tube  and  catheter.  The  tube  is  raised  and  straightened  in  order 
to  completely  empty  it.  It  is  then  tightly  pinched  between  the  finger 
and  thumb,  and  the  catheter  is  withdrawn.  By  this  means  not  a  drop 
of  the  liquid  will  find  its  way  into  air  passages. 

Tube  feeding  may  be  preceded  by  a  little  cocain  sprayed  on  the  back 
of  the  throat,  and  the  patient  is  propped  up,  or  in  the  sitting  posture. 
In  our  experience,  unless  a  part  of  the  jaw-bone  has  been  removed, 
the  patient  can  swallow  liquids,  while  sitting  up,  on  the  second  or  third 
day  after  operation. 

Packing  within  the  mouth  should  be  removed  piecemeal  as  it 
loosens,  the  free  ends  being  clipped  off  with  sharp  scissors.  After  the 
whole  packing  has  been  removed,  it  may  or  may  not  be  replaced. 
If  there  is  a  drain  in  the  floor  of  the  mouth,  it  is  seldom  necessary  to 
replace  it,  but  a  mildly  antiseptic  wash — weak  permanganate  of  potas- 
sium solution — should  be  used  frequently.  The  antiseptic  packing 
should  be  continued  as  long  as  it  will  be  retained,  if  the  wound  in  the 
floor  is  not  clean. 


CHAPTER  XXXIX. 

TUBERCULIOUS   AND   MALIGNANT  DISEASES   OE   THE 
CERVICAL  LYMPHATICS. 

Certain  localized  infections  of  the  lymphatics  are  best  treated  by 
radical  excision  of  the  diseased  tissues. 

In  malignant  disease,  whether  primary  or  secondary,  this  is  with 
rare  exception  the  only  treatment  that  gives  any  chance  of  cure.  In 
tuberculous  infections  of  the  lymphatics,  the  age,  resistance,  and  hy- 
gienic surroundings  of  the  patient  and  the  activity  of  the  disease  must 
be  considered  in  deciding  between  conservative  and  radical  treatment 
of  an  individual  case. 

TUBERCULOUS  ADENITIS. 

Tuberculous  diseases  of  the  lymph,  nodes  on  one  or  both  sides  of 
the  neck  usually  result  from  infection  through  the  teeth,  tonsil,  or 
nasopharynx,  less  commonly  from  the  middle  ear  or  mastoid  antrum, 
or  from  the  nodes  of  the  opposite  side.  It  is  seldom  that  the  exact 
portal  of  infection  is  recognized.  Tuberculous  lesions  of  the  mouth, 
throat,  and  ears  are  much  less  common  than  is  tuberculous  adenitis, 
although  in  systematic  examinations  the  bacilli  may  occasionally  be 
demonstrated  in  the  cavity  of  a  tooth,  in  the  crypt  of  the  tonsil,  or 
lodged  in  some  other  place.  It  is  an  accepted  fact  that  the  bacilli 
may  enter  the  lymphatics  without  causing  a  recognizable  inflamma- 
tion at  the  portal  of  entry. 

Symptoms  and  Course. — The  course  of  a  tuberculous  adenitis  is 
usually  rather  chronic,  but  it  is  occasionally  very  acute.  The  ordinary 
history  is  that  a  single  nodule  appears,  commonly  in  the  upper  cervical 
or  submaxillary  group,  slowly  enlarges,  and  later  other  such  kernels 
follow.  At  first  these  remain  discrete,  but  later  there  is  a  tendency 
to  fuse  into  a  somewhat  lobulated  mass.  In  the  meantime,  chains  of 
hard,  small  nodules  may  be  developed  in  several  other  groups,  so  that 
the  palpable  enlargement  may  be  confined  to  one  chain  or  group  of 
nodes,  or  may  be  felt  all  over  one  or  both  sides  of  the  neck.  The 
isolated  nodules  are  hard,  rounded,  and  movable;  while  the  conglom- 
erate masses  become  somewhat  fixed,  and  a  softening  can  sometimes 
be  detected  in  some  of  the  larger  nodules.  Even  after  the  nodes  have 
become  quite  large,  resolution  may  take  place.  This  is  more  likely 
to  occur  if  the  original  atrium  of  infection  is  removed  and  the  patient 

693 


594  SURGERY  OF  THE  MOUTH  AND  JAWS. 

is  placed  under  good  hygienic  conditions.  Usually,  after  one  or  more 
nodes  become  markedly  enlarged,  they  caseate,  and  a  cold  abscess  may 
result.  Before  the  age  of  seven  years  cold  abscess,  is  extremly  com- 
mon. If  the  mass  is  not  extirpated  at  this  time,  sinuses  may  result. 
These  are  persistent,  and  their  external  opening  is  usually  surrounded 
by  an  area  of  bluish  discoloration.  They  heal  slowly,  often  only  to 
recur,  and  when  healed,  leave  unsightly  scars.  In  some  cases  there  is 
less  tendency  to  form  abscesses  or  sinuses,  and  the  mass  enlarges  until 
its  presence  causes  considerable  disfigurement. 

In  the  acute  cases  the  nodes  rapidly  enlarge ;  there  are  fever,  loss  of 
weight,  and  the  ordinary  general  symptoms  of  an  active  tuberculous 
infection. 

In  the  chronic  cases  there  is  little  or  no  fever  and  no  pain,  and  the 
patient  suffers  remarkably  little  in  general  health.  In  these  chronic 
cases  there  is  a  very  distinct  tendency  to  ultimate  recovery.  If  a 
secondary  pus  infection  occurs,  there  will  be  all  of  the  signs  of  acute 
septic  inflammation.  Tuberculous  adenitis  is  almost  essentially  a  disease 
of  children  and  early  adult  life,  seldom  being  seen  after  thirty  years. 

Diagnosis. — The  majority  of  children  between  the  ages  of  four 
and  twelve  years  have  palpable  lymph  nodes,  and  chronic  enlargement 
of  the  lymph  nodes  from  simple  hyperplasia  is  not  uncommon  in  early 
adolescence.  Moderate  enlargement  of  the  nodes  cannot  be  taken  as 
the  basis  of  a  diagnosis  of  tuberculous  infection.  When  a  tuberculous 
infection  advances  to  the  stage  of  causing  excessive  enlargement  of 
certain  nodes  or  a  group  of  nodes,  then  the  diagnosis  is  usually,  but 
not  always,  simple.  There  is  little  danger  of  confounding  the  disease 
with  enlargement  due  to  acute  septic  infection.  In  the  more  chronic 
forms  of  simple  irritation,  the  nodes  have  not  the  tendency  to  fuse 
together  in  masses,  and  when  periadenitis  is  present,  the  outline  of 
the  glands  is  not  so  distinct  as  in  tuberculous  adenitis.  Syphilis,  lympho- 
sarcoma, Hodgkin's  disease,  endothelioma,  and  secondary  carcinoma, 
all  cause  an  increasing  enlargement  of  the  nodes ;  but  if  one  will  con- 
fine operative  interference  to  cases  in  which  there  is  a  persistent  and 
an  increasing  localized  enlargement  of  the  nodes,  will  always  remove 
all  of  the  lymph-bearing  tissue,  and  will  seek  the  atrium  of  infection, 
except  in  the  case  of  syphilis  or  of  Hodgkin's  disease,  the  mistakes  in 
diagnosis  will  not  be  detrimental  to  the  patient.  On  section,  a  tuber- 
culous node  may  show  an' apparently  simple  hyperplasia  or  it  may  be 
caseated.  Even  microscopically  the  diagnosis  may  be  difficult,  and 
the  safest  plan  for  making  a  diagnosis  in  uncertain  cases  is  the  injec- 
tion of  fresh  material  into  a  guinea  pig. 

Treatment. — It  was  the  observation  of  many  of  the  older  clinicians 
that  a  chronic  tuberculous  adenitis  gave  an  immunity  against  the  more 


MALIGNANT  DISEASES  OF  THE  LYMPHATICS.  595 

active  types  of  the  disease.  The  value  of  such  observations  is  not 
to  be  lightly  treated,  and  in  this  instance  it  corresponds  to  our  more 
newly  acquired  knowledge  of  antitoxins.  In  spite  of  this,  modern 
aseptic  surgery  has  placed  at  our  disposal  therapeutic  measures  that  can 
be  advantageously  employed  in  many  of  the  more  active  processes. 

In  the  earlier  stages  and  in  cases  in  which  there  is  not  deformity 
from  the  enlargement  of  the  nodes,  in  which  the  nodes  are  not  enlarg- 
ing, are  not  breaking  down,  and  in  which  the  patient's  general  health 
is  not  affected,  radical  surgical  treatment  is  not  indicated.  Possible 
sources  of  infection  should  be  sought  and  eradicated.  In  children  en- 
larging cervical  lymphatics  is  sufficient  indication  for  removing  ragged 
or  enlarged  tonsils  and  adenoids,  and  the  teeth  should  receive  attention 
when  decayed.  Of  course,  any  other  gross  lesions  should  also  be  cor- 
rected. The  patient  should  be  placed  under  proper  hygienic  con- 
ditions. In  this  regard,  the  choice  of  treatment  might  be  determined 
by  the  circumstances  of  the  patient.  A  patient  that  can  be  sent  to 
the  country  or  to  some  proper  climate  might  very  properly  be  spared 
an  operation  that  would  be  positively  indicated  in  an  inhabitant  of  a 
tenement  house.  For  children,  cod-liver  oil  has  been  considered  a 
great  help  in  treating  tuberculous  infections  and  the  anemia  that  ac- 
companies them. 

In  a  tuberculous  adenitis  the  infection  is  inclosed  within  a  wall  of 
granulations  and  the  gland  capsule.  The  local  circulation  is  meager, 
and  it  is  not  reasonable  to  expect  any  very  great  effect  from  specific 
agents,  such  as  tuberculin;  but  this  might  be  helpful  in  preventing 
the  spread  of  the  disease  to  other  nodes  or  from  becoming  diffused. 
In  this  respect,  tuberculin  injections  might  be  very  properly  made  just 
before  and  after  a  radical  operation  to  prevent  general  diffusion  of  the 
bacilli.  The  injection  of  vaccines  and  toxins  should  be  done  only  by 
one  who  has  made  some  study  of  this  subject,  for  they  may  produce 
more  harm  than  good  if  improperly  used.  Cases  in  which,  in  spite  of 
the  best  obtainable  conditions,  the  glands  are  enlarging  or  the  infection 
is  spreading  and  cases  in  which  the  glands  are  breaking  down  or  in 
which  there  are  persistent  general  symptoms  due  to  the  local  lymphatic 
infection  are  proper  ones  for  surgical  interference.  Except  in  young 
children  and  in  the  presence  of  open  sinuses,  the  operation  should  be 
radical  and  should  remove  all  of  the  infected  lymphatic  tissue.  A 
limited  apical  infection  of  the  lung  is  not  a  contraindication  to  an 
operation  for  a  rapidly  advancing  cervical  adenitis.  Cases  with  ad- 
vanced pulmonary  or  peribronchial  tuberculosis,  with  pharyngeal  infec- 
tion dependent  upon  pulmonary  disease,  or  with  extensive  involvement 
of  groups  of  glands  that  cannot  be  reached  should  be  excluded  from 
radical  operation.     The  radical  operation  for  tuberculous  adenitis  is 


596  SURGERY  OF  THE  MOUTH  AND  JAWS. 

based  upon  the  fact  that  for  a  time,  possibly  for  a  very  long  time,  the 
infection  is  confined  within  one  or  a  group  of  nodes  and  that  during 
this  period  the  infected  areas  can  be  removed  by  a  properly  planned 
and  executed  operation.  The  two  essentials  of  a  radical  operation 
are:  (1)  the  elimination  of  the  original  source  of  infection,  so  that 
tubercle  bacilli  will  not  be  poured  into  the  neck  wound  through  the 
cut  ends  of  the  lymphatic  ducts;  and  (2)  that  the  infected  mass  is  re- 
moved entirely,  and  preferably  in  one  piece.  In  this  way  there  is  no 
danger  of  leaving  infected  foci  or  of  disturbing  the  infection  during 
the  operation. 

There  is  a  feeling  on  the  part  of  most  surgeons,  which  we  share, 
that,  except  for  diagnostic  purposes  or  for  obtaining  material  for  making 
an  autogenous  vaccine,  single  nodes  should  seldom  be  removed,  but  the 
infected  group,  the  impalpable  as  well  as  the  palpable  ones,  should  be 
removed  en  masse  with  the  fascia  that  carries  them.  Of  late  there  is 
a  tendency  on  the  part  of  some  to  revert  to  the  older  plan  of  removing 
only  the  larger  nodes  and  to  depend  upon  hygienic  measures  to  over- 
come the  less  seriously  affected  in  the  same  group.  Just  how  far  the 
pendulum  will  swing  in  this  direction  is  impossible  to  say.  While  we 
are  satisfied  to  do  the  least  possible  surgery  on  babies  and  young  chil- 
dren on  account  of  their  peculiar  ability  to  overcome  the  infection,  in 
older  children  and  young  adults  we  prefer  to  remove  the  whole  group 
if  we  invade  the  neck  at  all.  In  children  and  babies  it  seems  wise  to 
repeatedly  aspirate  cold  abscesses  until  the  cavity  becomes  filled  with 
granulations.  In  aspirating,  strict  asepsis  is  preserved,  and  the  needle 
enters  the  neck  well  away  from  the  abscess  and  travels  through  at  least 

1  centimeter  of  the  subcutaneous  tissue  before  it  enters  the  cavity. 
Some  surgeons  inject  emulsions  containing  iodoform  crystals. 

Before  a  radical  operation  is  undertaken,  certain  preparatory  steps 
may  be  advisable.  The  patient  should  be  placed  in  the  best  possible 
physical  condition.  If  unruptured  pure  tuberculous  abscesses  are  pres- 
ent, these  not  deter  the  surgeon  from  operating,  but  it  may  be  advis- 
able to  withdraw  the  fluid  and  to  inject  a  very  small  quantity  of  a 

2  per  cent  solution  of  methylene  blue  into  the  cavity,  which  will  serve 
to  outline  it  during  the  operation.  In  this  way  the  sac  is  more  easily 
removed  without  rupture. 

Open  sinuses  that  have  a  mixed  infection  may  be  lightly  curetted 
at  a  preliminary  operation  and  packed  with  gauze,  soaked  in  a  weak 
formaldehyde  solution.  If  the  nature  of  the  septic  infection  can  be 
determined,  an  autogenous  vaccine  can  be  prepared,  and  a  course  of 
treatment  given  before  the  major  operation  is  undertaken.  It  is  a 
source  of  danger,  of  prolonged  postoperative  discomfort  to  the  patient, 
and  of  embarrassment  to  the  surgeon  to  have  an  extensive  suppura- 


MALIGNANT  DISEASES  OF  THE  LYMPHATICS.  39? 

tion  occur  in  the  immense  wound  that  remains  after  a  complete  removal 
of  the  lymphatic-bearing  fasciae  of  the  neck.  It  is  far  preferable  to 
allow  all  sinuses  to  heal  before  operating.  If  it  is  deemed  advisable 
to  operate  in  the  presence  of  a  sinus,  it  can  be  plugged  lightly  with 
gauze,  saturated  with  tincture  of  iodin.  At  operation  the  discolored 
skin  at  the  mouth  of  the  sinus  should  be  excised. 

When  the  infection  seems  limited  to  the  submental  and  sub- 
maxillary regions,  the  operation  may  be  planned  to  meet  this  limited 
infection,  but  it  is  always  safer  to  remove  all  of  the  lymphatic-bearing 
fisciae  and  nodes  below  the  site  of  the  infection.  In  about  80  per  cent 
of  cases  the  enlargement  first  appears  beneath  the  upper  end  of  the 
sternomastoid  muscle.  In  a  very  few  cases  it  will  be  found  to  have 
started  in  the  lower  part  of  the  neck.  In  any  case  all  of  the  lymphatic 
tissue  should  be  removed  cleanly  from  any  area  that  is  invaded  by  the 
surgeon.  Reoperation  is  more  difficult  and  less  likely  to  be  effective 
than  is  a  well-executed  primary  operation.  It  is  perfectly  proper  in 
selected  cases  to  divide  the  operation  into  several  stages — such  as,  for 
instance,  to  operate  upon  both  submaxillary  and  submental  groups  and 
then  take  the  lateral  cervical  nodes  at  two  subsequent  operations.  But 
it  is  never  proper  to  enter  any  area  without  removing  all  of  its  lymph- 
bearing  tissue.  In  spite  of  our  best  judgment  and  efforts,  recurrence 
will  somet'imes  happen,  and  we  shall  have  to  occasionally  reoperate  on 
our  own  as  well  as  on  other  cases. 

Radical  Operation  for  Tuberculous  Infection  of  the  Cervical 
Lymphatics. — Many  plans  have  been  devised  for  exposing  the  lym- 
phatic-bearing faciae  of  the  neck,  but  there  is  one  that,  while  giving 
perfect  access  to  the  operative  field,  does  so  with  very  little  disfigure- 
ment to  the  patient ;  and  this  we  will  describe.  As  far  as  we  know, 
it  was  first  used  by  Dr.  White,  of  Chicago,  and  is  probably  at  present 
the  most  popular  among  those  doing  truly  radical  operations. 

The  hair  should  be  shaved  for  2  centimeters  above  and  posterior  to 
the  normal  hair-line  on  that  side.  The  skin  is  prepared  down  to  the 
middle  of  the  sternum  and  well  past  the  midline  on  the  opposite  side. 
The  patient  lies  on  the  table  on  his  back  with  a  low  pillow  under  his 
shoulders.  The  incision  is  to  run  from  the  tip  of  the  mastoid  pro- 
cess to  a  point  3  centimeters  above  the  middle  of  the  clavicle,  and 
then,  turning  abruptly,  crosses  the  sternoclavicular  joint  to  a  point 
2  centimeters  be5^ond.  This  incision  is  to  be  outlined  before  the 
protective  cloths  are  clamped  into  place.  If  the  infection  does  not 
extend  forward  of  the  submaxillary  group,  all  diseased  tissue  can 
be  removed  through  the  incision  just  outlined. 

If  enlarged  nodes  are  situated  in  front  of  the  submaxillary  salivary 
gland,  a  supplementary  incision  will  have  to  be  made  if  this   tissue 


598  SURGERY  OF  THE  MOUTH  AND  JAWS. 

is  to  be  removed  at  the  same  operation,  and  this  must  be  borne  in  mind 
in  placing  the  protective  cloths.  We  prefer  m  all  operations  to  have 
the  protective  cloths  fastened  securely  to  the  skin.  This  takes  but 
a  few  minutes  and  relieves  the  operator's  mind  of  all  further  anxiety 
on  this  point.  The  upper  cloth  is  fastened  with  safety  pins  or  tenacu- 
lum forceps  along  the  border  of  the  jaw  and  hair-line  and  is  turned 
upward  over  the  hair  and  the  ether  mask.  Ether  is  subsequently 
poured  directly  on  this  cloth,  while  the  anesthetist  observes  the  pulse 
and  controls  the  position  of  the  head  with  one  hand  under  the  cloth. 
The  fastenings  of  the  cloth  that  skirts  the  posterior  border  of  the 
wound  should  be  placed  at  short  spaces,  for  there  is  a  tendency  for  this 
cloth  to  sag  away  from  the  skin  and  to  allow  the  handles  of  artery 
forceps  to  slip  under  it.  Only  several  centimeters  of  the  skin  incision 
should  be  made  at  a  time,  and  the  bleeding  should  be  controlled  with 
Halsted  forceps  or  heavier  clamps,  as  the  operator  prefers;  but  the 
whole  superficial  incision  should  be  completed  before  the  deeper  tissues 
are  disturbed.  The  skin  should  be  cut  squarely  through  and  not 
beveled,  as  this  renders  a  good  closure  difficult.  This  incision  should 
go  down  to  the  deep  fascia  covering  the  sternomastoid  muscle.  In  its 
middle  and  lower  parts  it  cuts  through  the  platysma  muscle.  The 
external  jugular  vein  is  exposed  and  doubly  ligated.  Schroeder  recom- 
mends that  the  proximal  part  of  the  vein  be  left  somewhat  long  on 
the  left  side,  as  it  might  be  useful  in  forming  anastomosis  with  the 
thoracic  duct,  should  the  latter  be  injured  subsequently.  We  have 
found  it  simpler,  after  resecting  the  duct,  to  implant  it  into  the  internal 
jugular  vein.  The  flap  is  dissected  forward  until  the  whole  posterior 
border  of  the  sternomastoid  is  defined.  The  lymphatic-bearing  fascia 
of  the  posterior  triangle  is  now  exposed  and  should  be  removed  en 
masse.  Before  this  is  begun,  the  spinal  accessory  nerve  which  enters 
the  gland  mass  from  beneath  the  posterior  border  of  the  sternomastoid 
muscle  should  be  found  and  dissected  free.  It  emerges  from  under 
the  sternomastoid  just  below  and  slightly  behind  the  angle  of  the  jaw, 
and  runs  downward  and  backward,  to  disappear  under  the  trapezius 
muscle.  It  should  be  freed  from  the  surrounding  tissue  throughout 
this  course  through  the  posterior  triangle.  It  should  not  be  crushed 
with  the  forceps,  but  may  be  lifted  with  a  loop  of  tape  or  catgut.  In 
weak,  growing  children  cutting  this  nerve  has  been  the  starting  of  a 
scoliosis  due  to  partial  paralysis  of  the  trapezius  muscle.  The  nerve 
may  be  identified  by  grasping  it  lightly  with  artery  forceps,  which  will 
cause  a  contraction  of  the  trapezius  muscle.  This  nerve  secured,  the 
cutaneous  branches  of  the  superficial  cervical  plexus  may  be  cut  as 
they  are  encountered,  for  their  preservation  in  the  dissected  area  is 
apt  to  be  followed  by  a  somewhat  persistent  neuralgia.     The  posterior 


MALIGNANT  DISEASES  OF  THE  LYMPHATICS. 


599 


border  of  the  sternomastoid  muscle  is  dissected  forward  until  the 
internal  jugular  vein  is  exposed.  Surgically  this  is  one  of  the  most 
important  structures  in  the  neck,  and  the  enlarged  nodes  may  be  ad- 
herent to  the  posterior  part  of  its  sheath.  About  the  middle  of  its 
course  there  are  usually  two  nodes  just  anterior  to  it  in  the  angle  be- 
tween  the   vein   and   the  omohyoid  muscle.     From   the   level   of   the 


JFig.  414.  Structures  displayed  in  a  radical  excision  of  the  deep  cervical  nodes. 
In  order  to  retract  the  wound  in  both  directions  at  once,  the  spinal  accessory  nerve  has 
been  cut.     It  should  be    preserved  in  a  resection  for  tubercular  adenitis. 


hyoid  bone  downward,  the  sheath  and  the  attached  glands  are  dissected 
from  the  vein.  In  doing  this,  it  is  safest  to  use.  a  dissecting  scissors 
or  a  pointed  artery  forceps,  thrusting  the  point  into  the  mass  of  fascia 
and,  by  spreading  the  blades,  investigating  each  mass  of  tissue  before 
it  is  cut.  When  the  mass  attached  to  the  vein  is  pulled  forcibly,  the 
vein,  from  which  the  blood  will  be  pressed  out,  is  easily  drawn  with  it 


600  SURGERY  OF  THE  MOUTH  AND  JAWS. 

and  may  be  caught  upon  the  end  of  the  scissors  and  cut.  When  work- 
ing close  to  the  vein,  the  outHne  of  the  wall  should  be  in  constant  view. 
When  recognized,  small  veins  should  be  caught  before  being  cut,  and 
all  bleeding  controlled.  Blood  in  the  tissues  obscures  the  view  and 
is  productive  of  accidents.  A  lateral  wound  in  the  jugular  vein  should 
be  immediately  sutured  with  fine  catgut;  a  transverse  cut  can  also  be 
sutured.  Ligation  of  one  internal  jugular  will  rarely  cause  trouble. 
As  soon  as  the  lower  part  of  the  internal  jugular  vein  is  well  exposed, 
it  will  be  seen  to  collapse  with  each  inspiration.  If  wounded,  this  nega- 
tive pressure  may  suck  in  air  (see  Air  Embolism,  page  59).  To  avoid 
this  possibility,  the  vein  may  be  blocked  and  kept  permanently  dis- 
tended by  stuffing  a  folded  strip  of  gauze  between  the  vein  and  the 
sternomastoid  muscle  at  the  root  of  the  neck.  A  part  of  this  strip  is 
left  protruding  from  the  wound.  The  mass  having  been  dissected 
free  from  the  lower  half  of  the  jugular,  it  may  have  to  be  freed 
from  the  subclavian  in  the  same  way.  Special  care  must  be  used  to 
get  a  node  that  may  be  found  close  in  the  angle  of  junction  of  these 
two  veins.  On  the  left  side  this  part  of  the  dissection  is  complicated 
by  the  thoracic  duct  that  enters  the  subclavian  vein  at  this  point. 
By  carefully  separating  the  tissues,  it  may  usually  be  found  without  dif- 
ficulty, as  it  turns  downward,  emerging  from  behind  the  internal  jugu- 
lar vein  (Fig.  414).  Except  at  its  lower  end,  it  is  well  behind  the 
lymph  nodes.  It  is  usually  well  distended  with  a  clear  fluid,  and  is  thus 
easily  distinguished  from  a  vein.  If  it  is  accidentally  cut  in  two,  an 
attempt  may  be  made  to  anastomose  it  with  the  proximal  end  of  the 
external  jugular  vein  or  to  implant  it  into  the  internal  jugular.  (Con- 
trary to  what  might  be  expected  from  the  supposed  anatomy  and  physi- 
ology of  this  duct,  section  and  non-repair  have  not  proved  to  be  a 
necessarily  fatal  accident,  but  may  be  follov^^ed  by  a  very  pronounced 
loss  of  weight.)  The  posterior  belly  of  the  omohyoid  muscle  is  seen 
crossing  the  lower  part  of  the  space.  Its  nerve  supply  comes  from 
the  ansa  hypoglossi,  which  lies  on  the  carotid  sheath,  and  this  should 
not  be  injured.  At  the  posterior  part  of  the  triangle  the  mass  may 
extend  far  under  the  trapezius  muscle,  which  latter,  if  necessary, 
may  be  cut  close  to  the  clavicle.  In  this  way  the  dissection  can  be 
extended  to  the  upper  limit  of  the  axilla.  If  palpable  nodes  can  be 
felt  in  the  axillary  space,  they  should  be  removed  at  a  subsequent 
axillary  operation.  When  the  glandular  mass  is  freed  anteriorly,  in- 
feriorly,  and  posteriorly,  it  is  dissected  upward  from  the  muscles  form- 
ing the  floor  of  the  triangle.  In  doing  this,  the  muscular  branches 
from  the  superficial  cervical  nerve  plexus  should  be  preserved,  but  if 
the  mass  is  adherent  to  the  muscular  sheaths,  this  may  be  difficult. 
Most  important  is  the  phrenic  nerve,   which  arises   from  the  third, 


MALIGNANT  DISEASES  OF  THE  LYMPHATICS.  6ni 

fourth,  and  fi^fth  cervical  nerves  and  is  seen  to  lie  upon  the  surface  of 
the  scalenus  anticus  muscle  and  runs  downward  to  disappear  under  the 
subclavian  vein.  Its  injury  would  be  a  very  serious  accident.  When 
this  part  of  the  dissection  is  completed,  the  cervical  portion  of  the 
brachial  plexus  is  plainly  in  view.  The  transversalis  colli  artery  and 
vein  lying  beneath  the  deep  layer  of  the  cervical  fascia  may  have  been 
cut.  In  the  upper  part  of  the  neck  the  lymph  nodes  will  be  found  to 
lie  superficial  to  and  under  the  sternomastoid  muscle.  The  skin  and 
superficial  fascia  are  to  be  dissected  free  from  the  superficial  lymph 
nodes  and  external  jugular  vein,  which  lie  upon  the  upper  third  of  the 
sternomastoid  muscle.  Next,  the  muscle  itself  is  freed  from  the  mass 
of  enlarged  glands  that  may  completely  surround  its  upper  end.  In 
raising  the  upper  part  of  this  muscle  from  the  subjacent  mass,  the 
spinal  accessory  nerve  that  here  enters  its  under  surface  is  to  be  freed 
without  injury.  If  the  spinal  accessory  and  the  muscular  branches 
from  the  third  and  fourth  cervical  nerves  were  both  cut,  there  would 
be  complete  paralysis  of  the  trapezius  muscle.  The  freeing  of  the 
diseased  mass  from  the  structures  beneath  it  is  now  continued.  The 
superior  deep  nodes  that  lie  around  the  bifurcation  of  the  carotid  are 
dissected  free.  In  doing  this,  the  hypoglossal  and  communicans  hypo- 
glossi  nerves  may  be  exposed.  These  must  not  be  injured.  The  dis- 
section is  continued  up  to  the  mastoid  process,  freeing  the  mass  from 
the  internal  jugular  vein.  Above,  the  gland-bearing  fascia  is  attached 
to  the  styloid  process,  the  base  of  the  skull,  and  also  to  the  transverse 
process  of  the  atlas,  from  which  it  must  be  cut.  At  the  lower  border 
of  the  parotid  gland,  it  may  be  found  impossible  to  establish  a  natural 
line  of  cleavage,  and  very  free  hemorrhage  from  numerous  small 
vessels  results  from  cutting  into  the  substance  of  this  gland.  The 
whole  mass  is  now  removed,  leaving  a  clean  dissection  of  the  posterior 
triangle  of  the  neck  and  the  carotid  sheath,  but  the  submaxillary  and 
submental  nodes  still  remain.  Nodes  situated  around  the  submaxillary 
salivary  gland  can  be  reached  by  retracting  the  sternomastoid  muscle 
and  drawing  the  skin  forward,  or  by  drawing  both  the  skin  flap  and 
muscle  forward  (Fig.  414).  The  submaxillary  nodes  lie  embedded  in 
the  fascial  sheath  of  the  salivary  gland,  which  sheath  must  be  removed 
with  the  nodes.  If  the  anterior  submaxillary  and  submental  nodes 
are  involved,  a  supplementary  skin  incision  is  required.  An  incision 
is  made  from  the  middle  of  the  body  of  the  hyoid  bone  in  the  direc- 
tion of  the  mastoid  process.  It  follows  the  skin  fold  and  runs  about 
2  centimenters  below  the  angle  of  the  jaw.  The  skin,  superficial  fascia, 
and  platysma  muscle  are  cut  through,  and  with  a  pair  of  sharp- 
pointed  rake  retractors  these  flaps  are  drawn  upward  and  downward 
until  the  lymphatic  mass  is  entirely  uncovered.     In  drawing  back  the 


602  SURGERY  OF  THE  MOUTH  AND  JAWS. 

upper  flap,  the  inframaxillary  branch  of  the  facial  nerve  (Fig.  415) 
should  be  sought  and  preserved.  It  is  probable,  but  not  necessary,  that 
the  branch  to  the  platysma  will  be  cut.  Beginning  at  the  lower  margin 
of  the  mass,  the  deep  fascia  is  incised.  The  facial  vein  is  either 
avoided  or  doubly  ligated.  The  mass  is  lifted  from  the  subjacent 
tendon  and  bellies  of  the  digastric,  stylohyoid,  and  mylohyoid  muscles, 
and  dissected  free  from  the  submaxillary  gland,  taking  with  the  mass 
the  facial  sheath  of  the  gland.  The  submental  nodes  lie  near  the 
midline  on  and  between  the  anterior  bellies  of  the  digastric  muscles. 
At  the  lower  border  of  the  jaw  the  fascia  containing  the  mass  is  cut 
across.  All  bleeding  vessels  that  have  been  caught  must  be  tied,  with 
the  possible  exception  of  the  skin  vessels.  This  may  be  tedious,  but 
it  is  the  safer  plan,  as  a  large  blood  clot  greatly  interferes  with  the 
healing  of  this  wound.  In  spite  of  the  best  technic,  this  wound  cannot 
be  considered  clean,  for  the  reason  that  the  lymphatic  vessels  from  the 


Fig.  415.     Inability  to  depress  the  angle  of  the  mouth,  due  to  damage  of  the  iufra- 
mandibular  nerve  at  a  submaxillary  operation  on  the  right  side. 

mouth  have  been  cut  across  and  empty  their  secretions  into  it.  For 
this  reason  drainage  of  every  part  should  be  carefully  provided. 
Through  a  stab  wound  made  posterior  to  the  lower  angle  of  the 
incision,  a  thin  folded  strip  of  rubber  dam  or  a  spirally  split  tube  is 
passed  under  the  sternomastoid  muscle  and  well  into  the  submaxillary 
space.  If  preferred,  the  submaxillary  space  may  be  drained  directly 
through  a  stab  wound  made  at  its  lower  part,  but  it  will  not  drain  past 
the  sternomastoid  muscle  into  the  lateral  neck  wound  unless  drainage 
is  provided  as  above  outlined.  No  matter  in  what  way  the  wound  is 
sutured,  the  platysma  should  be  well  approximated.  The  drain  that 
passes  under  the  sternomastoid  should  be  left  in  place  from  three  to 
six  days,  as,  all  lymphatic  vessels  having  been  .cut,  serum  is  at  first 
continually  poured  into  the  wound. 

Results  of  Radical  Operation. — It  is  our  observation  that  in  the 
majority  of  cases  operations  are  followed  by  very  good  results.     About 


MALIGNANT  DISEASES  OF  THE  LYMPHATICS.  603 

10  per  cent, of  all  patients  will  die  of  tuberculosis,  either  generalized 
or  localized,  most  commonly  pulmonary,  and  in  about  10  per  cent 
of  all  cases  the  disease  will  recur  locally  after  carefully  executed  oper- 
ations. 

SECONDARY    CARCINOMA   OF   THE    CERVICAL 
LYMPHATICS. 

The  cervical  lymphatics  will  sooner  or  later  become  infected  in 
every  case  of  carcinoma  or  lymphosarcoma  of  the  mouth  or  face,  rarely 
from  sarcoma.  (For  the  order  in  which  various  groups  may  become 
involved  and  a  description  of  the  clinical  appearance  of  carcinoma- 
tous nodes,  see  page  557  and  page  559.) 

Treatment. — It  is  our  belief  that,  with  the  possible  exception  of 
the  flat  carcinomata  of  the  lip  (page  474),  for  malignant  disease,  not 
only  should  all  of  the  nodes  in  one  or  both  sides  of  the  neck  be  removed, 
but  always  as  far  as  possible  the  nodes,  lymph  ducts,  and  the  periglan- 
dular tissue  should  be  removed  in  one  block.  It  was  Crile,  we  believe, 
who  first  emphasized  this  procedure,  and  his  operation  includes  the 
removal  of  the  sternomastoid  muscle  and  internal  jugular  vein.  Mait- 
land  advocates  a  less  radical  procedure  in  that  he  does  not  remove  the 
vein  as  a  routine  procedure.  We  agree  with  Maitland  who  removes 
the  internal  jugular  only  when  the  nodes  are  plainly  adherent  to  the 
vein  itself,  and  believe  that  there  are  strong  reasons  for  this  practice. 
Kocher  and  Butlin  both  advocate  a  less  radical  operation.  This  can- 
not be  done  as  quickly  as  the  block  excision,  and  there  is  good  reason 
to  believe  it  is  not  so  effective;  but  theirs  is  a  less  serious  operation 
and  may  be  indicated  in  earlier  cases.  The  operation  we  perform  in 
nearly  all  cases  of  carcinoma  of  the  mouth,  with  the  exception  of  flat 
ulcers  of  the  lips  and  carcinoma  of  the  maxilla,  is  essentially  as  follows  : 

The  submental  and  the  submaxillary  nodes,  including  the  platysma 
muscle,  are  removed  as  outlined  under  Carcinoma  of  the  Lip.  page  478, 
but  the  incision  is  made  as  follows : 

On  the  side  of  the  neck  it  is  outlined  as  for  a  radical  operation  for 
a  tuberculous  infection.  A  second  incision  is  outlined  from  the  symphy- 
sis of  the  jaw  to  the  middle  of  the  hyoid  bone,  and  then  straight  back- 
ward to  the  incision  on  the  side  of  the  neck.  The  upper  part  of  the 
lateral  incision  and  the  submaxillary  incision  are  made  through  the  skin, 
and  the  flap  is  reflected  upward  to  2  centimeters  above  the  lower  border 
of  the  jaw.  The  least  possible  amount  of  the  subcutaneous  tissue  is 
included.  The  submaxillary  and  submental  excisions  are  then  made 
as  stated.  The  incision  on  the  side  of  the  neck  is  next  completed. 
Above  the  level  of  the  hyoid  bone  th*"  platysma  muscle  is  raised  with 
the  flap. 


604  SURGERY  OF  THE  MOUTH  AND  JAWS. 

The  lower  anterior  flap  is  turned  forward  as  far  as  the  anterior 
border  of  the  sternomastoid  muscle.  The  clavicular  and  sternal  ori- 
gins of  this  muscle  are  cut,  and  the  mass  of  lymphatic  tissue  is  dissected 
up  from  the  muscular  floor  behind  the  internal  jugular  vein.  At  the 
angle  of  junction  of  the  subclavian  and  internal  jugular  on  the  left  side, 
care  should  be  taken  not  to  injure  the  thoracic  duct  (Fig.  414).  If 
the  tissues  can  be  freed  from  the  internal  jugular  vein,  it  is  left  in  place ; 
if  not,  the  vein  is  doubly  ligated  just  above  its  junction  with  the  sub- 
clavian and  cut  through,  and  the  vein  included  with  the  block  excision. 
The  anterior  belly  of  the  omohyoid  muscle  with  the  tissue  over  the 
thyrohyoid  muscle  is  removed,  as  the  latter  contains  a  node  that  re- 
ceives lymph  from  the  neighborhoood  of  the  frenum  linguae.  Usually 
there  are  two  nodes  situated  just  above  the  omohyoid  in  the  angle  be- 
tween it  and  the  jugular  vein.  As  the  dissection  proceeds  upward, 
the  mass  is  raised  from  the  muscles  forming  the  floor  of  the  posterior 
triangle,  and  from  the  contents  of  the  carotid  sheath.  All  nerves  of 
the  superficial  cervical  plexus  are  cut  as  they  are  encountered,  but  the 
phrenic  must  not  be  injured.  With  the  exception  of  the  common  and 
internal  carotid  arteries  and  the  phrenic  nerve,  any  or  all  structures  can 
be  removed  from  one  side  of  the  neck,  but  such  excisions  are  accom- 
panied by  largely  increased  risks.  The  various  tissues  encountered 
were  enumerated  in  the  description  of  the  dissection  for  tuberculous 
adenitis.  At  the  upper  angle  of  the  wound  the  sternomastoid  muscle  is 
cut  across  close  to  the  mastoid  process.  If  the  jugular  vein  is  included 
in  the  excision,  it  must  be  ligated  close  to  the  base  of  the  skull.  The 
lymphatic-bearing  fascia  is  cut  across  close  to  its  attachments  to  the 
mastoid  process,  the  transverse  process  of  the  atlas,  and  the  base  of  the 
skull.  It  sometimes  happens  that  the  upper  part  of  the  jugular  vein  is 
surrounded  by  a  dense  mass  of  hard  nodes.  At  first  these  look  rather 
hopeless,  but  with  patience  we  have  usually  found  that  the  vein  could  be 
freed,  and  that  between  the  cancerous  masses  and  the  base  of  the  skull 
there  was  almost  a  centimeter  of  soft  tissue  through  which  the  excision 
could  be  made.  The  flaps  are  approximated  with  sutures  and  clips, 
using  free  drainage  of  rubber  dam.  In  making  this  dissection,  Crile 
applies  a  temporary  clamp  to  the  common  carotid  artery.  We  do  not 
do  this,  because  the  trunk  of  the  vessel  is  in  plain  view  and  can  be  easily 
compressed  with  the  finger  at  any  time.  We  do  think  it  advisable,  how- 
ever, to  inject  a  drop  of  1  per  cent  novocain  solution  into  the  proximal 
part  of  every  nerve  large  enough  to  recognize  before  it  is  cut.  This 
lessens  the  shock.  This  is  a  very  extensive  dissection ;  and  before  it  is 
undertaken,  the  operator  should  plan  and  prepare  for  every  step,  and 
during  the  course  of  the  work,  the  exposed  tissue  should  as  much  as 
possible  be  protected,  with  either  the  flaps  or  hot  saline  towels.     After 


MALIGNANT  DISEASES  OF  THE  LYMPHATICS  605 

the  dressing  is  applied,  the  head  and  neck  and  shoulders  should  be 
firmly  bandaged  to  insure  the  approximation  of  the  flaps  to  the  deep 
tissues.  This  is  a  very  important  thing,  and  this  pressure  should  be 
maintained  until  the  flaps  become  firmly  united  to  the  deep  tissues. 

Results. — Operations  done  before  the  nodes  become  much  en- 
larged are  frequently  curative,  but  operations  done  when  the  nodes 
have  become  adherent  to  the  surrounding  tissues  are  rarely  more  than 
palliative. 


CHAPTER  XL. 

CONGENITAL  MALFORMATIONS,  INJURIES,  AND 
DISEASES  OF  THE  PHARYNX. 

While,  strictly  speaking,  the  pharynx  is  not  a  part  of  the  mouth, 
still  their  close  anatomical  and  physiological  relationship  and  the  fact 
that  in  many  diseases  the  lesion  may  occupy  both  cavities  lead  us  to 
believe  that  they  should  be  considered  together. 

ANATOMICAL  CONSIDERATIONS. 

The  pharynx  is  a  musculomembranous  bag  lined  with  mucous  mem- 
brane. It  is  attached  to  the  base  of  the  skull  behind  the  nasal  fossae 
in  front  of  the  vertebral  column.  Below,  it  is  continuous  with  the 
esophagus  at  the  lower  level  of  the  cricoid  cartilage,  and  is  larger 
above  than  below.  The  muscular  wall  is  complete  behind  and  laterally, 
where  it  is  in  close  relation  with  the  bodies  of  the  six  upper  cervical 
vertebrae  and  great  vessels,  separated  only  by  layers  of  the  deep  cervi- 
cal fascia,  and  in  places  by  a  few  muscles.  The  wall  is  lacking  in  front, 
the  deficiency  being  partly  filled  by  the  pharyngeal  surface  of  the  tongue 
and  the  body  of  the  larynx.  It  has  three  anterior  openings,  one  each 
for  the  nasal  fossa,  the  mouth,  and  larynx.  The  muscles  are  mostly 
constrictors,  which  are  active  in  deglutition,  phonation,  and  respiration. 
The  anatomical  and  physiological  relationship  of  the  pharynx  to  the 
three  cavities  opening  into  it  is  maintained,  not  only  by  a  continuity 
of  their  mucous  lining,  but  also  by  the  attachment  of  one  of  the  three 
pharyngeal  constrictors  at  the  lateral  border  of  each  of  the  three 
openings.  In  front,  the  pharynx  has  a  muscular  attachment  to  the 
pterygoid  process,  the  pterygomaxillary  ligament,  the  hyoid  bone,  and 
the  thyroid  cartilage.  Posteriorly  it  has  no  direct  attachment  to  the 
surrounding  structures,  being  separated  from  them  by  a  layer  of  cellular 
tissue.  With  respect  to  the  three  anterior  openings,  the  pharynx  is 
anatomically  divided  into  three  parts :  the  naso-  or  epipharynx,  the  oro- 
or  mesopharynx,  and  the  laryngo-  or  hypopharynx. 

The  nasopharynx  is  situated  above  the  level  of  the  hard  palate,  and 
normally,  during  the  act  of  swallowing  or  of  oral  respiration,  is  com- 
pletely shut  oflf  from  the  oral  part  of  the  tube,  partly  by  elevation  of 
the  velum  and  partly  by  contraction  of  the  superior  constrictor.  An- 
teriorly it  communicates  with  the  nasal  fossae  through  the  posterior 
nares,  while  on  each  of  its  lateral  walls  at  the  level  of  the  middle  turbi- 

60« 


DISEASES  OF  THE  PHARYNX  607 

nated  bone  is  found  the  Eustachian  cushion  and  the  opening  of  the 
Eustachian  canals.  From  the  posterior  part  of  the  Eustachian  cushion, 
a  fold  passes  downward  on  the  side  of  the  pharynx,  known  as  the 
tubopharyngeal  fold.  Behind  the  Eustachian  cushion  is  a  deep  lateral 
depression,  known  as  the  fossa  of  Rosenmiiller,  or  the  pharyngeal 
recess.  In  the  mucous  membrane  of  the  roof  is  a  collection  of  lym- 
phoid tissue,  known  as  the  pharyngeal  tonsil.  The  oral  portion  of  the 
pharynx  extends  from  the  level  of  the  hard  palate  to  the  hyoid  bone, 
and  communicates  with  the  mouth  through  the  isthmus  of  the  fauces, 
which  is  bounded  above  by  the  velum,  below  by  the  root  of  the  tongue, 
and  laterally  by  the  anterior  and  posterior  faucial  pillars.  Between 
the  latter  is  a  space  known  as  the  tonsillar  sinus,  in  which  lies  the 
faucial  tonsil,  another  collection  of  lymphoid  tissue  which  is  consid- 
ered as  belonging  to  the  pharynx.  The  faucial  and  pharyngeal  tonsils, 
together  with  a  collection  of  similar  tissue  on  the  root  of  the  tongue, 
form  a  ring  known  as  Waldeyer's  lymphoid  ring,  which  surrounds  the 
nasal  and  oral  openings  of  the  pharynx.  Lymphoid  tissue  may  be 
found  in  less  amount  in  Rosenmiiller's  fossa  and  on  the  posterior 
pharyngeal  wall.  These  lesser  collections  are  called  lymphoid  follicles. 
The  base  of  the  tongue  is  connected  with  the  upper  surface  of  the 
epiglottis  by  a  median  line  of  mucous  membrane,  on  each  side  of  which 
is  a  shallow  pouch  known  as  the  vallecula. 

The  laryngopharynx  extends  from  the  hyoid  bone  to  the  lower 
border  of  the  cricoid  cartilage  where  it  merges  into  the  esophagus. 
The  anterior  wall  of  the  laryngopharynx  is  formed  by  the  larynx, 
with  which  it  communicates  through  the  glottis.  This  part  is  de- 
marked  from  the  oropharynx  by  the  epiglottis,  and  there  are  two 
mucous  folds  extending  from  the  lateral  border  of  the  root  of  the 
tongue  to  the  epiglottis,  known  as  pharyngoepiglottic  folds.  On  either 
side  of  the  opening  of  the  glottis,  which  is  bounded  by  the  aryepi- 
glottic  folds,  is  a  pocket  called  the  recessus  piriformis  which  leads 
downward.  These  structures  and  spaces,  as  well  as  those  in  the  naso- 
pharynx, can  be  felt  with  the  finger  and  seen  with  a  laryngoscopic 
or  posterior  rhinoscopic  mirror. 

CONGENITAL  MALFORMATIONS  OF  THE  PHARYNX. 

Congenital  malformations  of  the  pharynx,  other  than  cleft  of  the 
velum,  are  very  rare.  Atresia  of  the  posterior  nares  may  be  congen- 
ital, due  to  lack  of  complete  obliteration  of  the  oral  plate,  that  at 
one  time  separated  the  pharynx  from  the  primitive  mouth  and  nose 
cavity.  The  condition  causes  complete  nasal  obstruction.  (For  its 
treatment,  see  page  288.)  Occasionally  the  nasal  septum  extends  back 
into  the  nasopharynx.     Sometimes  unilateral  or  bilateral  clefts  occur 


608 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


at  the  side  of  the  velum,  which,  when  congenital,  probably  represent  a 
failure  of  union  at  this  site  of  the  first  branchial  arch — to  which  belongs 
the  tensor  palati  muscle — and  the  second  arch — from  which  the  anterior 
faucial  pillar  is  derived.  It  is  Bruck's  opinion  that  such  lateral  clefts 
are  sometimes  acquired,  due  to  syphilis  or  diphtheria. 

Branchial  Fistula. — Congenital  branchial  fistulae,  sinuses,  or 
cysts  are  sometimes  present,  which  represent  a  failure  of  complete 
closure  of  the  openings  that  may  occur  during  development  at  the  site 
of  the  gill  slits.  In  the  mammalian  embryo  there  are  four  blind  clefts 
on  each  side.  The  entoderm  of  the  pharynx  protrudes  in  a  succes- 
sion of  parallel  out-pocketings  which  meet  corresponding  ectodermal 
depressions.     Entoderm  and   ectoderm   fuse  where  they  meet,  and  in 


Fig.    416. 


Fig    417. 


Fig.  416.  Branchial  fistula  of  the  first  cleft,  bilateral.  The  pit  can  be  seen  in 
front  of  the  upper  part  of  the  ear. 

Fig.  417.  Branchial  fistula  of  second  cleft.  A  blind  pouch  was  connected  Inter- 
nally with  the  cartilage  of  the  external  auditory  canal.  Fistulae  representing  the  first 
or  second  cleft  are  of  rare  occurrence. 

fishes  they  rupture  at  these  sites,  making  the  gill  slits  or  branchial 
clefts.  According  to  Stohr,  in  mammals  the  clefts  are  represented  by 
ectodermal  depressions,  and  if  they  ever  rupture  through,  the  defect 
is  usually  soon  obliterated,  so  that  permanent  openings  on  the  side 
of  the  pharynx  are  rarely  found.  The  first  gill  slit  is  represented  by 
the  external  auditory  canal  and  the  Eustachian  tube.  Sinuses  or  cysts 
that  represent  imperfect  closure  of  this  cleft  are  usually  found  close 
to  the  ear  (Fig.  416).  The  second  cleft  normally  closes  entirely,  but 
is  represented  upon  the  pharyngeal  surface  by  Rosenmiiller's  fossa  and 
the  tonsillar  recess  (Fig.  417).  Internally,  the  inner  openings  of  the 
third  and  fourth  clefts,  which  also  close,  are  represented  on  the  side  of 
the  pharynx  by  an  ill-defined  fold  in  front  of  the  laryngeal  nerve  and 
by  the  sinus  piriformis  respectively.     According  to   Stohr,  the  third 


DISEASES  OF  THE  PHARYNX.  609 

and  fourth  clefts  form  a  single  deep  recess  on  the  side  of  the  neck, 
known  as  the  cervical  sinus,  which  persists  only  in  pathological  cases, 
and  is  the  source  of  branchial  fistulae. 

These  fetal  remains  may  be  represented  in  the  developed  human 
in  several  ways.  There  may  be  a  complete  epithelial-lined  sinus 
leading  from  the  skin  of  the  neck  to  the  wall  of  the  pharynx.  The 
defect  may  be  represented  by  an  epithelial-lined  fistula  that  opens  only 
on  the  skin  surface — an  external  fistula — or  it  may  be  connected  only 
with  the  pharynx — an  internal  fistula.  The  epithelial  remains  may 
communicate  neither  with  the  skin  nor  mucous  membrane,  in  which 
case  they  form  branchial  cysts  or  dermoids,  depending  upon  the  char- 
acter of  epithelium  with  which  they  are  lined.  Though  they  are  nec- 
essarily congenital,  they  may  not  become  evident  until  some  years  after 
birth,  though  the  site  of  the  external  opening  may  be  marked  by  a 
nodule.  These  nodules  are  supposed  to  represent  supernumerary  cervi- 
cal auricles,  may  sometimes  contain  cartilage,  or  may  be  represented 
by  pigmented  spots.  The  presence  of  such  a  nodule  does  not  always 
indicate  the  presence  of  a  sinus  or  cyst. 

Diagnosis. — When  there  is  an  external  opening,  it  may  be  per- 
manent, or  there  may  be  an  intermittent  rupture  with  a  discharge  of 
fluid.  If  they  become  infected,  they  are  distended  with  pus  and  may 
be  surrounded  by  a  considerable  area  of  inflammation.  If  the  sinus 
communicates  with  the  pharynx,  the  pus  is  usually  very  offensive.  As 
a  rule,  little  is  to  be  learned  by  an  attempt  to  pass  a  probe.  In 
some  instances  it  has  been  found  that,  after  freeing  the  external 
opening  from  the  surrounding  skin,  a  probe  could  be  passed  into  the 
pharynx.  Of  the  several  we  have  dissected  out,  none  consisted  of  a 
straight  tube  that  could  be  followed  by  a  probe,  for  the  external  part 
of  the  fistula  consisted  of  a  series  of  irregularly  shaped  epithelial 
pouches.  We  have  been  able  to  inject  methylene-blue  solution  di- 
rectly into  the  pharynx  so  as  to  stain  a  gauze  pad,  but  in  one  instance 
the  sinus  burst,  diffusing  the  blue  throughout  the  neighboring  neck 
tissues,  which  was  embarrassing  at  a  subsequent  operation. 

The  diagnosis  is  usually  based  on:  the  location  of  the  external 
opening,  near  the  anterior  border  of  the  sternomastoid  muscle;  its 
persistency,  recurring  intermittently;  the  findings  at  operation;  and 
the  microscopical  appearance  of  the  tissue.  It  is  most  likely  to  be  con- 
founded with  a  persistent  sinus  leading  to  a  tuberculous  lymph  node. 
If  there  is  no  internal  or  external  opening,  there  will  be  simply  a  tumor 
in  the  side  of  the  neck. 

Trmtment. — Owing  to  the  difficulty  that  may  attend  the  excision 
of  a  complete  fistula,  it  has  been  deemed  best  by  some  to  simply  pro- 
vide drainage  at  the  external  opening.     Under  this  treatment  the  canal 


610  SURGERY  OF  THE  MOUTH  AND  JAWS. 

may  shrink  to  its  smallest  capacity  and  give  little  trouble.  The  injec- 
tion of  escharotic  fluids  is  not  apt  to  be  attended  with  success,  as  it  is 
practically  impossible  to  destroy  all  of  the  epithelial  lining. 

The  only  radical  treatment  is  excision.  If  it  is  a  blind  pocket  con- 
nected only  with  the  skin,  this  is  a  simple  matter ;  but  if  it  is  a  complete 
fistula,  it  is  often  very  difficult,  as  the  inner  part  of  the  tube  may  be 
very  delicate  and  uncertain  of  identification.  If  one  were  fortunate 
enough  to  be  able  to  pass  a  probe  through  the  full  length  of  the  fistula, 
this  would  form  a  guide  that  could  be  easily  followed.  If  the  incision 
in  the  skin  can  be  made  transversely,  no  objectionable  scar  will  result. 

According  to  the  embryology  of  the  arches,  a  fistula  representing 
the  second  cleft  would  run  between  the  stylohyoid  muscle  and  liga- 
ment in  front,  and  the  internal  carotid  artery  and  stylopharyngeus 
muscle  behind.  One  of  the  third  cleft  would  run  between  the  stylo- 
pharyngeus and  superior  constrictor  muscles  and  internal  carotid 
artery  above,  and  the  middle  constrictor  below ;  while  one  of  the  fourth 
cleft  would  run  below  the  middle  constrictor.  When  working  in  the 
neck  in  following  such  a  tract,  it  is  well  to  bear  in  mind  that  under  the 
stress  of  necessity  any  structure  that  is  likely  to  be  encountered,  except 
the  common  and  internal  carotid  arteries,  the  superior  laryngeal,  vagus, 
glossopharyngeal,  and  hypoglossal  nerves,  may  be  divided.  The  vagus 
or  the  glossopharyngeal  is  not  likely  to  present  serious  difficulties,  and 
the  stylohyoid  and  digastric  muscles  can  be  repaired.  In  spite  of  this, 
the  following  of  a  fistula  between  these  structures  is  always  a  difficult 
and  tedious  procedure. 

In  operating  upon  a  fistula,  the  external  incision  should  be  made 
large  so  that,  after  freeing  the  outer  part,  the  sternomastoid  can  be 
retracted  and  the  region  of  the  stylohyoid  ligament  and  muscle  can  be 
freely  exposed.  The  fistula  must  be  followed  right  to  the  pharynx. 
For  a  sinus  representing  the  second  cleft,  better  access  may  be  had  to 
the  inner  end  of  the  tract  by  excising  the  ramus  of  the  jaw  as  in  the 
original  Mikulicz  pharyngotomy  (see  page  625).  Unless  the  inner  end 
of  the  tract  is  removed,  leakage  from  the  pharynx  will  cause  a  recur- 
rence of  the  fistula.  If  the  fistulous  tract  has  been  preserved  intact 
as  it  is  dissected  toward  the  pharynx,  and  it  is  found  impracticable  to 
follow  it  to  its  natural  inner  opening,  the  following  suggestion  which 
we  noticed  in  some  medical  journal  may  be  followed : 

At  some  convenient  point  of  the  neck  the  pharynx  is  opened,  and 
the  distal  end  of  the  fistulous  tract  is  implanted  into  the  pharyngeal 
mucosa.  This  may  not  absolutely  prevent  accumulation  within  the 
fistula ;  but  accumulation  is  less  likely  to  occur  here  than  in  a  long- 
necked  fistula,  and  both  ends  of  the  fistula  will  now  discharge  into  the 
pharynx. 


DISEASES  OF  THE  PHARYNX.  611 

Pharyngeal  Pouches. — The  mucous  membrane  of  the  pharynx 
sometimes  Bulges  laterally  between  the  muscles.  These  may  repre- 
sent incomplete  fistulae  that  communicate  only  with  the  pharynx. 
According  to  Bruck,  the  lateral  diverticula,  seen  in  elderly  persons, 
occur  in  connection  with  the  upper  part  of  the  esophagus  and  are  usually 
acquired. 

INJURIES  OF  THE  PHARYNX. 

The  pharynx  is  sometimes  severely  burned  from  the  swallowing  of 
scalding  liquids  or  caustics.  Such  injuries  may,  if  the  patient  survives, 
be  followed  by  severe  scar  contraction.  The  pharynx  may  be  wounded 
by  any  sort  of  penetrating  object,  most  commonly  by  sticks  thrust  in 
the  mouth  or  by  falling  with  a  pipe  in  the  mouth.  If  the  wound  is  in 
the  velum  or  posterior  wall,  little  real  damage  is  usually  done,  but  if 
the  velum  is  torn  through  its  posterior  border,  it  should  be  immediately 
sutured.  A  simple  puncture  needs  no  specific  treatment.  Wounds  in 
the  faucial  pillars  or  tonsil  are  sometimes  much  more  serious,  as  a  large 
blood  vessel  may  be  injured,  possibly  with  fatal  hemorrhage.  A  stick 
or  a  pipe  stem  has  been  broken  ofif  in  a  lateral  pharyngeal  wound  and 
for  the  time  overlooked.  Such  a  foreign  body  might  give  rise  to  an 
abscess  or  to  subsequent  fatal  hemorrhage.  Morrant  Baker  reports 
such  a  cause. 

ACUTE  INFECTIONS. 

Acute  Pharyngitis. — This  is  most  commonly  associated  with  an 
acute  infection  of  the  nasal  passages  or  may  be  a  part  of  a  general 
inflammation  of  the  air  passages,  including  the  bronchi. 

Acute  Tonsillitis. — This  may  be  of  a  simple  catarrhal  variety  in 
which  the  mucous  covering  is  red  and  swollen.  In  the  follicular  va- 
riety yellowish-white  dots  will  be  seen  over  the  surface  of  the  inflamed 
tonsil,  which  are  evidence  of  suppuration  and  accumulations  of  epi- 
thelium in  the  mouths  of  the  tonsillar  follicles. 

Phlegmonous  Pharyngitis. — A  phlegmonous  inflammation  may 
attack  any  part  of  the  pharynx,  due  to  a  penetrating  infection  with 
pyogenic  bacteria.  The  favorite  site  is  in  the  retropharyngeal  con- 
nective tissue  or  in  the  connective  tissue  around  the  tonsil.  Suppura- 
tion within  the  tonsil,  not  confined  to  the  crypts,  is  rather  rare.  The 
pharynx  may  be  attacked  by  a  true  erysipelas,  either  primarily  or  as  an 
extension  from  the  skin.  Phlegmonous  inflammation  of  the  pharynx 
may  cause  considerable  swelling,  and  if  this  is  in  the  neighborhood  of 
the  glottis,  respiration  may  be  so  impeded  as  to  necessitate  tracheotomy. 

Tonsillar  Abscess. — This  is  usually  unilateral,  the  tonsil  becom- 
ing large  and  painful  with  general  symptoms  of  suppuration ;  later, 
softening  may  be  detected. 


613  SURGERY  OF  THE  MOUTH  AND  JAWS. 

Peritonsillar  Abscess. — In  peritonsillar  abscess  the  pillars  and 
the  neighboring  parts  of  the  velum  and  pharynx  all  become  red  and 
swollen,  but  the  tonsil  itself  often  shows  little  evidence  of  inflammation. 
Inspection  is  difficult ;  but  if  seen,  the  anterior  pillar,  half  of  the  velum, 
and  the  uvula  will  be  swollen  and  edematous,  the  tonsil  being  still  little 
changed,  but  almost  hidden.  Half  of  the  faucial  isthmus  will  be 
blocked  by  the  swelling.  As  the  swelling  increases,  there  is  pain,  in- 
creased by  motion — such  as  moving  the  head,  opening  the  mouth, 
and  swallowing.  There  are  the  usual  general  symptoms  of  suppura- 
tion, a|id  palpation  will  at  first  reveal  a  spot  of  greatest  tenderness 
which  corresponds  to  the  focus  of  suppuration.  Later  a  localized 
softening  will  be  felt,  which  means  that  a  distinct  abscess  has  formed. 
If  it  is  not  opened  artificially,  the  abscess  usually  bursts  in  a  few  days, 
when  the  symptoms  will  subside;  rarely  the  abscess  burrows  into  the 
retropharyngeal  space.  In  one  case  that  came  to  autopsy  shortly  after 
entering  the  City  Hospital,  the  pus  had  burrowed  along  the  preverte- 
bral space  down  into  the  posterior  mediastinum.  A  very  large  abscess 
may  cause  considerable  dyspnea,  and  when  it  bursts  or  is  opened,  the 
pus  may  be  aspirated  into  the  larynx.  A  peritonsillar  abscess  has 
been  known  to  ulcerate  into  the  internal  carotid  artery,  causing  fatal 
hemorrhage.  Tonsillar  and  peritonsillar  abscess  have  a  distinct  ten- 
dency to  recur  in  some  persons. 

Treatment  of  Tonsillar  and  Peritonsillar  Abscess. — In  the  very 
early  stages  ice  may  be  applied  externally  to  the  space  under  the  jaw, 
and  bits  of  ice  may  be  dissolved  in  the  mouth.  As  soon  as  a  distinct 
spot  of  increased  tenderness  has  been  identified  by  palpating  with  the 
end  of  the  finger,  or  if  seen  later  and  a  softened  spot  can  be  detected, 
it  should  be  opened.  This  can  be  done  with  little  extra  pain,  after 
painting  the  surface  with  10  per  cent  cocain.  The  site  of  election  for 
opening  a  peritonsillar  abscess  is  1  centimeter  above  the  anterior 
faucial  pillar,  which  will  be  depressed  and  run  rather  horizontal.  The 
knife  should  be  guarded  by  wrapping  the  blade  with  cotton  to  within 
1  centimeter  of  the  point,  so  that  it  will  cut  but  1  centimeter  deep.  The 
incision  is  carried  toward  the  midline.  If  pus  is  not  formed,  the 
patient  will  for  a  time  be  somewhat  relieved,  but  the  incision  may  have 
to  be  repeated.  It  is  for  this  reason  that  many  operators  prefer  not 
to  open  a  peritonsillar  abscess  until  it  is  well  defined.  A  pair  of  round- 
nosed,  narrow-bladed  artery  forceps,  thrust  into  the  wound  and  spread, 
will  usually  liberate  the  pus,  if  the  original  incision  was  anywhere  near 
the  abscess. 

Persistent  and  severe  hemorrhage  might  follow  the  opening  of  a 
peritonsillar  abscess,  but  this  is  not  liable  to  occur  unless  the  incision 
was  made  very  deep  and  far  external.     Bleeding  may  follow  the  spon- 


DISEASES  OF  THE  PHARYNX.  r.l3 

taneous  rupture  of  the  abscesses,  or,  rather,  the  rupture  may  be  due  to 
hemorrhage,  which  results  from  necrosis  of  the  wall  of  an  artery. 
Arterial  bleeding  is  most  apt  to  be  from  the  ascending  pharyngeal  or 
the  internal  carotid  artery.  If  the  bleeding  cannot  be  controlled  by 
packing,  by  the  pressure  of  a  Proebstring  or  Mikulicz-Stork  tonsillar 
clamp,  or  by  digital  pressure — all  of  which  are  extremely  painful  in 
an  inflamed  area — resort  should  be  had  to  ligating  the  external  carotid 
low  down,  so  as  to  control  the  ascending  pharyngeal  artery,  and  at  the 
same  time  placing  another  ligature  loosely  around  the  part  of  the 
common  artery.  If  the  bleeding  conies  from  the  internal  carotid,  it 
will  not  be  arrested  by  the  first  ligature,  and  the  second  will  have  to  be 
drawn  tight.  Even  the  recurrent  circulation  from  the  upper  end  of 
the  internal  carotid  might  continue  bleeding  with  a  fatal  termination. 
Ligation  of  the  common  carotid  in  young  persons  is  not  apt  to  be  fol- 
lowed by  serious  consequences. 

Retropharyngeal  Abscess. — Retropharyngeal  abscess  causes  the 
posterior  wall  of  the  pharynx  to  bulge  forward.  It  may  be  caused  by 
extension  from  a  peritonsillar  or  a  parotid  abscess,  suppuration  in  the 
temporomandibular  joint,  or  by  suppuration  originating  in  the  pharyn- 
geal tissue.  In  children  under  five  years  there  are  some  lymph  nodes 
in  the  prevertebral  connective  tissue  in  front  of  the  second  and  third 
cervical  vertebrae,  which  later  atrophy.  When  present,  these  are  im- 
portant etiological  factors  in  the  development  of  retropharyngeal  ab- 
scess. 

Retropharyngeal  septic  abscesses  are  usually  preceded  by  a  pharyn- 
gitis or  tonsillitis,  but  the  onset  of  the  retropharyngeal  inflammation 
may  be  very  acute,  or  somewhat  insidious,  with  symptoms,  particularly 
in  children,  that  are  not  very  characteristic.  There  may  be  mild  fever, 
malaise,  disinclination  to  take  food,  and  some  swelling  of  the  cervical 
nodes  and  throat,  but  a  difficulty  of  swallowing  and  breathing  and  a 
tendency  to  cough  after  taking  fluids  may  be  the  first  symptoms  that 
point  to  serious  trouble.  The  difficulty  of  swallowing  may  be  so  great 
that  fluids  regurgitate  through  the  nose.  Later  there  will  always  be 
the  general  symptoms  that  accompany  acute  septic  infection. 

Examination  will  show  a  dusky  redness  of  the  pharyngeal  wall, 
which  is  covered  by  a  viscid  mucus,  and  if  palpated,  it  will  be  found  to 
be  bulging  forward  in  some  part,  usually  unilateral.  The  abscess  may 
be  low  down,  so  that  it  can  be  detected  only  by  palpation.  In  older 
children  and  adults  the  swelling  may  be  seen  with  a  laryngoscopic 
mirror,  if  the  mouth  can  be  opened  sufficiently,  but  palpation  is  always 
the  most  efficient  mode  of  examination.  The  swelling  is  felt  to  be 
circumscribed  and,  when  pressed  upon  the  pharyngeal  wall,  yields  in 
front  of  the  finger.     The  posterior  pharyngeal   wall   normally   rests 


614  SURGERY  OF  THE  MOUTH  AND  JAWS. 

firmly  against  the  border  of  the  vertebra.  True  fluctuation  cannot  be 
eHcited  with  one  finger. 

Secondary  tuberculous  abscess  usually  follows  after  caries  of  the 
bodies  of  the  spinal  vertebrae.  It  rarely  follows  tuberculous  infection 
of  the  retropharyngeal  lymph  nodes.  It  is  always  subacute  in  onset  and 
manifests  itself  mainly  by  pressure  symptoms.  If  due  to  spinal  caries, 
the  characteristic  stiffness  of  the  cervical  spine  will  be  found.  Unless 
there  is  a  secondary  pyogenic  infection,  the  symptoms  of  an  acute  pus 
infection  will  be  absent. 

Treatment. — The  secondary  tuberculous  abscess  is  but  an  acci- 
dent of  the  spinal  disease,  and  is  to  be  treated  as  part  of  the  latter; 
incidentally  it  might  be  stated  that  a  tuberculous  abscess  should  never  be 
opened  through  the  pharyngeal  wall.  A  septic  abscess  not  of  tuber- 
culous origin  should  be  opened  through  the  pharyngeal  wall  if  it  has  not 
begun  to  point  in  the  neck,  but  if  the  latter  circumstance  has  occurred, 
it  might  in  some  cases  be  opened  from  the  outside. 

The  incision  in  the  pharyngeal  wall  should  be  sufficiently  free  to 
insure  free  drainage  and  should  be  carried  to  the  lower  part  of  the 
abscess  cavity.  If  the  abscess  is  situated  high  up  in  older  children,  the 
incision  may  be  made  after  painting  the  surface  with  10  per  cent  cocain, 
or  20  per  cent  novocain;  but  in  young  children  and  in  all  cases  where 
the  abscess  is  low  down,  the  incision  had  best  be  made  under  a  general 
anesthetic.  The  blade  of  the  bistoury  is  wrapped  with  cotton  to  within 
1  centimeter  of  the  point,  and  the  abscess  is  localized  with  the  index 
finger  of  one  hand,  as  this  serves  as  a  guide  to  the  knife.  After  punc- 
turing the  abscess,  the  incision  is  carried  from  above  downward,  or  the 
reverse.  The  opening  should  be  at  least  large  enough  to  admit  the 
finger.  In  one  case  of  a  large  abscess  that  extended  from  the  third  to 
the  sixth  cervical  body,  in  a  child  two  years  of  age,  we  opened  it  at 
the  upper  end  and,  inserting  the  finger  to  the  bottom  of  the  cavity, 
pressed  laterally  into  the  neck.  With  the  other  hand  and  the  help  of 
an  assistant,  we  dissected  down  to  the  finger  from  the  outside  and 
carried  a  drainage  tube  from  the  external  incision  well  up  into  the 
abscess.  It  was  held  in  place  by  a  skin  suture.  This  gave  dependent 
external  drainage. 

If  the  abscess  is  large  and  there  have  been  considerable  dyspnea  and 
coughing  after  attempts  to  take  fluid,  we  believe  it  wise  to  precede  the 
opening  of  the  abscess  by  a  laryngotomy  for  two  reasons:  (1)  The 
sudden  opening  of  a  large  abscess  is  apt  to  be  followed  by  aspiration, 
if  the  child  is  struggling  for  breath.  (2)  The  swelling  and  stiffness 
of  the  tissues  around  the  entrance  of  the  glottis  allow  fluids  to  enter 
the  larynx,  which  accounts  for  the  coughing  that  accompanies  attempts 
to  take  fluids.     It  is  safer  to  have  the  tube  left  in  the  larynx  until  the 


DISEASES  OF  THE  PHARYNX.  015 

child  can  swallow  normally,  and  until  this  occurs,  fluids  should  be 
given  only  with  the  child  in  inverted  position. 

ADHESIONS    OF    THE    VELUM    AND    FAUCES    AND 

PHARYNGEAL   WALL— STRICTURE 

OF  THE  PHARYNX.i 

Adhesions  and  contractures  of  the  pharynx  may,  according  to  their 
location,  be  divided  into  three  kinds:  (1)  those  in  the  neighborhood 
of  the  velum,  which  lessen  or  occlude  the  communication  between  the 
oro-  and  the  nasopharynx;  (3)  those  which  form  in  the  fauces,  which 
lessen  the  size  of  the  communication  between  the  mouth  and  the  phar- 
ynx; and  (3)   those  which  constrict  the  hypopharynx. 

Adhesions  and  contractures  may  be  in  more  than  one  part  of  the 
pharynx.  Palate  adhesions  can  be  the  result  of  simple  inflammatory 
conditions  of  the  mucous  membrane,  of  deep  ulcerations  from  syphilis, 
lupus,  etc.,  of  destruction  by  caustics,  or  of  wounds,  either  accidental 
or  the  result  of  ill-devised  operative  measures.  Some  few  cases  have 
been  congenital.  The  condition  may  be  anything  from  a  simple  ad- 
hesion of  one  mucous  surface  to  another,  or  adhesion  of  two  bare  mus- 
cular surfaces  without  the  deposit  of  much  fibrous  tissue,  to  the  union 
of  broad  masses  of  scar  with  deep  destruction,  infiltration,  and  dis- 
tortion of  the  tissues. 

Owing  to  the  constant  motility  of  the  parts,  simple  adhesions  of 
the  mucous  membranes  are  not  liable  to  occur.  When,  however,  there 
is  deep  ulceration,  especially  as  the  result  of  gumma,  the  subsequent 
contraction  will  distort  the  tissues,  which  in  healing  are  apt  to  acquire 
abnormal  attachments.  Such  attachments  are  especially  liable  to  occur 
if  the  ulceration  occupies  apposing  surfaces,  such  as  the  wall  of  the 
nasopharynx  and  the  upper  surface  of  the  velum.  Complete  shutting- 
off  of  the  nasopharynx  may  follow  rather  slight  inflammation  when 
there  is  a  perforation  of  the  palate,  through  which  the  patient  breathes, 
which  allows  the  inflamed  fauces  and  velum  to  remain  at  rest. 

Contractures  at  the  junction  of  the  nasopharynx  and  oropharynx 
may  cause  few  symptoms,  even  when  very  extensive,  but  if  the  de- 
structive ulceration  and  subsequent  scarring  approaches  the  Eustachian 
cushions,  deafness  may  result. 

If  the  stenosis  is  complete,  unless  there  is  palate  perforation,  there 
will  be  mouth-breathing,  inability  to  blow  mucus  from  the  nose,  and 
possibly  insufficient  aeration  of  the  middle  ear  cavity.     Usually  there 


1  An  exhaustive  paper  on  the  subject  of  adhesions  in  the  upper  part  of  the 
pharynx,  including  a  history  of  attempts  at  correction,  and  the  bibliographical  ref- 
erences was  presented  by  John  A.  Roe  (Journal  of  the  A.  M.  A.,  Vol.  LIV,  No.  3, 
page  185,  Jan.  1,  1910)  before  the  section  on  laryngology  and  otology  of  the  Ameri- 
can Medical  Association. 


616  SURGERY  OF  THE  MOUTH  AND  JAWS. 

is  some  modification  of  the  voice.  Contractures  in  the  faucial  isthmus 
and  hypopharynx  are  never  complete,  for  death  would  result  from  lack 
of  food  or  air.  There  have  been  cases  in  which  the  faucial  isthmus 
was  the  size  of  a  lead  pencil,  or  smaller,  and  in  these  the  patient  could 
take  only  liquid  food.  In  stricture  of  the  isthmus  the  tongue  is  usually 
drawn  somewhat  upward  and  backward.  Stricture  of  the  hypo- 
pharynx,  due  to  swallowing  caustic  fluids,  usually  extends  into  the 
esophagus. 

The  practical  points  of  interest  in  any  case  are :  the  extent  and  loca- 
tion of  the  adhesions  upon  which  will  depend  the  advisability  of  oper- 
ative interference;  and  the  amount  of  ulceration  and  scar  infiltration 
that  caused  the  adhesions.  Upon  the  latter  will  largely  depend  .the 
quality  of  the  operative  results.  If  they  are  the  result  of  a  simple  ad- 
hesive inflammation,  breaking-up  of  the  adhesions  and  preventing  their 
return  will  restore  the  normal  condition.  If  there  have  been  extensive 
loss  of  tissue  and  wide  infiltration  with  hard  scar,  the  operative  results 
can  at  best  be  a  poor  compromise. 

Treatment.^ — If  the  adhesions  are  due  to  agglutination  of  the 
mucous  surfaces,  simply  freeing  them  with  the  finger  or  a  blunt  instru- 
ment and  the  repeated  application  of  some  unguent  or  silver  leaf  will 
be  all  that  is  needed.  We  have  an  analogous  condition  in  an  adherent 
prepuce.  For  the  more  serious  conditions,  due  to  loss  of  epithelium, 
to  scar  contraction,  and  malunion  of  the  tissues,  almost  every  con- 
ceivable scheme  has  been  tried  in  the  past,  for  their  relief.  In  many 
of  them  the  operator  had  apparently  lost  complete  sight  of  the  fact  that 
where  scar  tissue  is  removed  or  cut,  unless  the  raw  surface  be  covered 
with  epithelial  tissue,  contraction  tends  again  to  occur;  and  that  where 
a  raw,  newly  scarred  area  is  continuous  over  two  apposed  surfaces, 
union  of  these  surfaces  is  almost  certain  to  result.  The  latter  phe- 
nomenon is  well  illustrated  in  the  difficulty  in  maintaining  the  cleft 
after  separating  webbed  fingers. 

Dilators  have  held  a  prominent  place  in  these  operations,  but  except 
in  a  very  limited  class,  dilatation  can  be  of  very  little  good.  If  the  scar 
tissue  remains,  the  dilator  would  have  to  be  used  for  an  indefinite 
period. 

If,  by  some  mechanical  means,  small  isolated  or  narrow  linear  raw 
surfaces  can  be  prevented  from  coming  in  contact  with  other  raw 
surfaces  until  after  the  neighboring  epithelium  has  been  drawn,  or 
grown  over  them,  then  some  good  will  have  been  accomplished.  Pack- 
ing, dilators,  and  the  pressure  of  bands  passing  around  the  velum  from, 
the  nasal  to  the  oral  cavity  have  all  been  used  for  this  purpose.  For 
incomplete  shutting-off  of  the  nasopharynx,  by  adhesions  at  the  pos- 
terior border  of  the  velum,  Nichols  proposed  the  application  of  the  old 


DISEASES  OF  THE  PHARYNX. 


617 


plan  that  has-been  used  in  operating  on  webbed  fingers.  It  consists  in 
introducing  a  silk  strand  through  the  outer  part  of  the  adhesion,  the 
strand  transfixing  the  tissues  that  separate  the  nasal  from  the  oral 
pharynx.  The  nasal  end  of  the  suture  is  drawn  down  through  the  still 
patented  opening,  and  the  silk  is  tied  loosely  in  the  form  of  a  ring. 
This  procedure  is  a  counterpart  of  the  plan  of  placing  a  silk  ligature  in 
the  lobe  of  the  ear  after  piercing  it.  It  is  allowed  to  stay  in  place 
until  an  epithelization  of  the  tract  has  occurred,  and  then,  without 
wounding  the  outer  wall  of  this  tract,  the  palate  is  cut  loose  from 
the  pharynx.  It  seems  to  us  that  the  best  plan  to  protect  this  new 
epithelial  tract  and  to  make  certain  that  the  incision  opens  it  accu- 
rately would  be  to  pass  a  probe  through  the  tract  and  cut  down  upon 
the  latter.     Roe  used  silver  wire  for  the  same  purpose  in  three  cases. 


Fig.  418.  iiine  of  incision  for  using  the  anterior  faucial  pillar  for  covering  raw 
surface  on  the  nasopharynx  or  velum. 

This  plan  is  applicable  only  when  the  adhesion  is  small  or  the  line  of 
adhesion  is  narrow  and  not  infiltrated.  A  quicker  result  under  such 
circumstances  might  be  obtained  by  exposing  the  nasopharynx  by 
splitting  the  velum  in  the  midline  and  freeing  the  adhesions.  Then 
obliterate  the  raw  surfaces  on  the  velum  by  suturing  the  edges  of  the 
mucous  membrane  over  the  defect  with  fine  tannated  catgut,  and  repair 
the  split  velum  (Fig.  418). 

Where  the  ulceration  has  been  deep  and  extensive,  as  much  of  the 
constriction  will  be  due  to  contraction  and  distortion  as  to  adhesion. 
These  are  most  difficult  cases  to  relieve  by  operative  measures.  As  a 
rule,  if  there  is  a  fair  breathing  space,  an  operation  is  not  indicated, 
unless  perhaps  it  be  to  enable  the  aurist  to  use  the  Eustachian  catheter. 
If  the  tongue  is  bound  up  so  as  to  interfere  with  function,  the  scars 


618  SURGERY  OF  THE  MOUTH  AND  JAWS. 

may  be  dissected  out  and  replaced  with  flaps  turned  from  the  cheeks. 
If  it  is  deemed  advisable  or  essential  to  separate  the  velum  from  the 
pharyngeal  wall,  it  may  be  done  with  an  angular  knife,  or  scissors, 
after  splitting  the  velum. 

With  a  stricture  limited  to  the  faucial  isthmus,  it  is  a  comparatively 
simple  thing  to  excise  sufficient  scar  tissue  to  give  a  free  opening  and 
to  cover  the  resulting  raw  surface  with  a  flap  of  mucosa  from  the 
cheek,  or  even  a  flap  of  skin  and  subcutaneous  tissue  turned  from  the 
neck  through  a  high  lateral  pharyngotomy  wound.  In  the  lower  part 
of  the  oropharynx,  or  in  the  hypopharynx,  strictures  are  best  treated 
by  the  use  of  dilators  that  will  maintain  the  patency  of  the  canal. 
These,  however,  must  be  so  constructed  as  to  permit  breathing  while 
they  are  in  use.  When  the  contractures  are  thick  and  firm,  it  may  be 
necessary  to  precede  dilatation  by  cutting  the  bands,  either  through  the 
mouth  or  by  a  lateral  pharyngotomy  wound.  After  cutting  the  bands, 
or  excising  the  scar  from  the  hypopharynx,  it  would  be  a  safe  plan  to 
pass  a  dilator  at  regular  intervals.  But  from  the  reported  cases,  it 
would  appear  that  there  is  not  the  same  tendency  for  the  stricture  to 
return  in  the  lower  pharynx  as  there  is  near  the  velum,  and  in  most 
cases  simple  cutting  of  the  bands  has  been  sufficient. 

Prognosis. — In  cases  where  inconvenience  is  caused  by  contrac- 
tion and  distortion  of  the  fauces  or  the  hypopharynx,  operative  inter- 
ference and  dilatation  may  be  undertaken  with  the  hope  of  relieving 
the  condition. 

The  same  is  true  of  all  palate  adhesions  where  there  has  been  little 
loss  of  tissue  and  but  slight  deposit  of  fibrous  tissue.  But  where  the 
velum  and  pharynx  are  incorporated  in  a  thick  mass  of  scar  tissue,  all 
that  can  be  accomplished  is  to  establish  a  breathing  and  feeding  space. 
If  these  are  already  present,  the  case  had  best  be  let  alone.  The  oper- 
ation is  not  free  from  danger,  and  is  liable  to  be  followed  by  a  post- 
operative discomfort  out  of  proportion  to  the  good  accomplished. 


CHAPTER  XLI. 

TUMORS   OF  THE   VELUM,   TONSILS,   AND    PHARYNX. 

A  number  of  varieties  of  tumors  occur  in  the  pharynx  and  in  the 
vekim.  The  inaccessibility  of  the  pharynx  and  its  close  proximity  to  es- 
sential nerves  and  vessels  and  to  the  spinal  column  are  apt  to  render 
malignant  growths  inoperable  in  a  comparatively  early  stage  of  their 
growth. 

TERATOMATA. 

Teratomata  occurring  in  the  soft  palate  or  pharynx  have  the  fol- 
lowing peculiarities :  They  usually  take  the  form  of  pedunculated 
skin-covered  tumors,  the  central  part  consisting  of  a  solid  core  of  con- 
nective tissue,  bone,  cartilage,  and  a  variable  amount  of  striped  mus- 
cle tissue.  The  skin  is  usually  beset  with  hairs,  and  sometimes  the 
tumor  contains  teeth.  The  tumors  are  usually  small  and  pedunculated ; 
it  may  be  difficult  to  tell  if  a  certain  one  originates  from  the  base  of 
the  skull  or  the  palate.  Sometimes  they  are  sessile  below,  but  may 
project  through  the  floor  of  the  pituitary  fossa,  causing  local  intra- 
cranial pressure. 

It  is  noteworthy  that  pedunculated  skin-covered  and  pilose  tumors 
are  found  only  at  the  two  extremities  of  the  notochord,  in  the  naso- 
pharynx, and  near  the  rectum.  In  describing  these,  Bland-Sutton 
points  out  their  probable  relation  to  dichotomy,  which  may  be  limited  to 
the  bones  of  the  face,  in  which  case  the  supernumerary  maxillae  may 
fuse  together,  impacted  in  the  nasopharynx  and  fixed  to  the  base  of 
the  sphenoid  bone.  He  has  described  specimens,  mostly  in  the  Royal 
College  of  Surgeons'  Museum,  showing  various  degrees  of  this  con- 
dition, from  a  well-formed  maxilla  with  unerupted  teeth  to  a  conglom- 
erate mass  of  bone,  teeth  and  cartilage  impacted  in  the  palate  and 
firmly  fixed  to  the  base  of  the  sphenoid  bone.  In  one  case  in  which  two 
pigs  were  attached  to  each  other  by  the  lateral  aspect  of  their  heads, 
every  part  was  complete  in  duplicate,  except  the  mandibles.  After  a 
careful  search,  the  missing  pair  of  mandibles  were  found  hanging  in 
the  pharynx  as  a  teratoma. 

The  treatment  of  these  tumors  is  removal ;  the  ease  or  difficulty  of 
this  will  depend  very  much  upon  their  size  and  attachment.  Some  are 
attached  by  stalks  or  pedicles  that  are  easily  severed.  Sometimes  they 
apparently  take  their  origin  from  the  palate,  but  really  arise  in  the 

(U9 


620  SURGERY  OF  THE  MOUTH  AND  JAWS. 

nasopharynx.     The  nasopharynx  can  be  exposed  by  splitting  the  velum, 
with  or  without  removing  part  of  the  bony  plate  (page  288). 

BENIGN  TUMORS. 

Papilloma,  fibroma,  angioma,  lipoma,  osteoma,  and  enchondroma 
occur  and  give  few  symptoms  except  those  due  to  their  size.  Papillo- 
mata  may  be  single  or  multiple  about  the  oral  part  of  the  pharynx,  may 
have  smooth  or  cauliflower-like  surfaces,  and  may  be  from  the  size  of 
a  pinhead  to  a  pea.  On  the  tonsil  they  may  be  in  the  form  of  a  pe- 
dunculated growth  that  shows  tonsil  structure.  Retention  cysts  may 
occur,  arising  in  the  roof  of  the  pharynx,  due  to  blocking  the  median 
recess.  If  by  their  size  any  of  these  tumors  cause  annoyance,  all  but 
the  angiomata  and  the  retention  cysts  may  be  excised. 

Vascular  Tumors. — Vascular  tumors  are  not  uncommon  in  this 
region  and  are  more  commonly  composed  of  blood  vessels  than  lym- 
phatics. Of  the  blood-vessel  tumors,  the  cavernous  angiomata  are  the 
most  common  and  are  more  frequently  situated  upon  the  edge  of  the 
velum  and  palate  arches.  They  may  become  very  large,  extending  be- 
yond the  limits  of  the  pharynx,  and  are  then  a  menace  to  life  on  account 
of  hemorrhage. 

The  treatment  of  these  is  probably  best  done  by  the  use  of  the 
electric  or  actual  cautery  punctures,  with  a  needle  at  a  dull-red  heat. 
It  usually  requires  a  number  of  treatments  to  obliterate  the  tumor. 
The  lymphatic  angiomata  may  occur  here  as  well  as  on  the  tongue, 
and  are  subject  to  recurrent  attacks  of  inflammation.  If  they  cannot 
be  excised,  they  might  be  treated  with  the  electric  cautery,  and  at  a 
time  when  the  tumor  is  not  acutely  inflamed.     Excision  is  preferable. 

Racemose  and  true  aneurysm  may  occur.  The  former  rarely  causes 
severe  trouble.  The  latter  may  arise  from  the  internal  maxillary  or 
other  branches  of  the  external  carotid.  Probably  the  best  treatment 
of  true  aneurysm  in  this  situation  is  ligation  of  the  vessels  that  supply 
it.  Varicose  veins  are  more  common  on  the  pharyngeal  surface  of  the 
tongue,  but  may  occur  on  the  pharyngeal  wall.  As  a  rule,  they  give 
rise  to  few  symptoms,  but  when  indicated,  they  can  be  treated  as  cav- 
ernous angiomata. 

Kummel  calls  attention  to  certain  lipomata  and  fibromata  originating 
near  the  laryngeal  opening,  and  tending  to  grow  in  finger-like  processes 
that  may  hang  down  into  the  larynx  or  the  esophagus.  They  may  cause 
asphyxia,  or  other  less  serious  symptoms.  Becoming  spontaneously 
detached,  they  may  be  coughed  up  or  swallowed.  If  their  point  of 
origin  be  made  out,  they  can  be  grasped  with  forceps  at  the  base  and 
torn  loose. 

There  are  three  other  recognized  groups  of  tumors  relative  to  the 


TUMORS  OF  THE  PHARYNX.  621 

pharynx  that  are  usually  benign,  are  rare,  and  for  one  reason  or  an- 
other are  of  particular  interest :  the  palate  adenoma,  the  nasopharyngeal 
polypus,  and  the  retropharyngeal  tumor,  most  commonly  called  goiter. 

PALATE  ADENOMA. 

Palate  adenoma,  so  designated  by  Bland-Sutton,  but  is  described  by 
Bruck  simply  as  intramural  tumor.  They  are  very  rare  and  occur 
either  at  the  posterior  part  of  the  hard  palate  or  in  the  velum.  They 
may  vary  in  size  to  several  centimeters  across,  and  usually  possess 
perfect  capsules,  from  which  they  are  easily  enucleated.  The  benign 
non-ulcerated  cases  are  to  be  distinguished  from  gummata  by  the  fact 
that  the  tumors  are  freely  movable  under  the  mucous  membrane.  But 
this  may  rupture,  in  which  case  the  tumor  resembles  a  gumma  or  ma- 
lignant growth.  From  their  exposed  position,  they  are  somewhat  prone 
to  ulceration,  forming  deep  crater-like  ulcers  and  causing  a  marked 
odor.  Their  structure  is  complex  and  variable,  and  they  are  difficult 
of  classification.  They  have  been  placed  among  the  dermoids,  tera- 
tomata,  and  salivary  gland  tumors.  According  to  Bland-Sutton,  they 
may  show  glandular  tissue  with  ducts  buried  in  the  struma  that  re- 
sembles sarcomatous  tissue.  Epithelial  pearls  may  be  present,  some 
being  keratinous.  Myxomatous  tissue  may  be  present,  and  also  lym- 
phoid follicles. 

No  doubt,  encapsulated  tumors  of  various  kinds  have  been  included 
under  the  head  of  palate  adenoma,  but  there  seems  to  be  good  reason 
for  the  belief  that  the  majority  of  them  bear  a  somewhat  close  relation 
to  mixed  salivary  gland  tumors.  They  occasionally,  after  a  prolonged 
benign  course,  show  very  marked  malignancy,  which  is  a  distinct  char- 
acteristic of  the  mixed  salivary  gland  tumors.  Kiimmel  states  that 
the  palate  tumor  may  have  its  origin  in  the  parotid,  extending  into  the 
velum  through  the  wall  of  the  pharynx.  The  tumors  may  appear  at 
puberty,  but  usually  between  the  thirtieth  and  fiftieth  year. 

Treatment. — They  are  almost  always  benign,  and  their  treat- 
ment consists  simply  in  enucleation.  Those  that  have  taken  on  or 
show  malignancy  will  have  to  be  treated  accordingly. 

NASOPHARYNGEAL  POLYPUS  OR   NASOPHARYN- 
GEAL FIBROMA. 

This  is  a  non-malignant  fibroma  that  usually  arises  in  the  roof  of 
the  nasopharynx  from  the  cartilage  of  the  occipital  bone,  and  follows 
a  peculiar  clinical  course.  They  occur  almost  exclusively  in  males 
at  about  the  age  of  puberty.  They  grow  at  first  within  the  naso- 
pharynx, the  nasal  fossa,  and  pharynx,  but  later  perforate  through 
the  sphenopalatine  foramen,  and  invade  the  sphenomaxillary  fossa,  the 
orbit,  maxillary  antrum,  and  zygomatic  and  temporal  fossae,  and  ac- 


622  SURGERY  OF  THE  MOUTH  AND  JAWS. 

quire  new  attachments  as  they  grow.  In  this  form  they  have  heen 
described  by  Langenbeck  as  retromaxillary  tumors  (page  450).  The 
tumor  can  cause  absorption  of  the  bone  and  in  this  way  may  penetrate 
the  skull  and  invade  the  cranial  cavity  or  the  palate.  We  have  seen 
pieces  of  the  tumor  attached  to  teeth  that  were  extracted  because  the 
wall  of  their  sockets  had  become  invaded.  At  the  age  of  twenty  or 
twenty-five  years  they  tend  to  stop  growing  and  even  retrograde.  In 
some  cases  they  are  said  to  have  become  sarcomatous.  Although  from 
the  fact  that  they  do  not  cause  metastasis  they  must  be  regarded  as 
benign,  still  from  their  location  and  their  peculiar  habit  of  forming  new 
attachments  they  are,  when  extensive,  extremely  difficult  to  eradicate. 

Histologically  the  polypus  consists  of  dense  fibrous  tissue,  but  the 
vessels  may  be  very  numerous ;  and  when  the  growth  protrudes  from 
the  nostril,  it  presents  a  soft,  red,  easily  bleeding  mass.  If  the  tumor 
perforates  into  the  skull,  there  may  be  signs  of  intracranial  pressure. 

Treatment. — Treatment  of  the  intrapharyngeal  growths  should 
be  their  complete  removal  and  the  destruction  of  the  base  with  the 
electric  or  actual  cautery.  This  procedure  would  be  facilitated  by 
splitting  the  velum  and  even  removing  the  palate  processes.  The 
treatment  of  the  more  extensive  growths  was  discussed  under  retro- 
maxillary tumors  (page  451). 

RETROPHARYNGEAL  GOITRE. 

This  is  described  by  Bruck  as  a  tumor  behind  the  lower  part  of  the 
pharynx,  arising  from  a  lateral  lobe  or  an  aberrant  part  of  the  thyroid 
gland.  Hajek  saw  one  and  Braun  two  supernumerary  thyroid  glands 
in  this  region.  It  is  a  slow-growing  tumor  that  does  not  cause  trouble 
until  it  reaches  a  certain  size  and  bulges  forward  the  posterior  wall  of 
the  pharynx.  The  tumor  is  very  vascular,  and  if  it  perforates  the 
pharyngeal  wall,  may  cause  hemorrhage,  or  become  inflamed.  In  a 
case  of  Wolfier's,  the  tumor  did  not  develop  until  an  enlarged  thyroid 
lobe  had  been  removed.  If  examined  through  the  pharyngoscope,  it 
is  seen  to  move  up  and  down  in  swallowing.  Unless  it  arises  from  an 
aberrant  thyroid,  it  can  be  moved  laterally  only  in  one  direction,  owing 
to  its  attachment  to  the  lateral  lobe  of  the  thyroid  gland.  It  can  be 
made  to  produce  a  bulging  at  the  side  of  the  neck,  at  the  level  of  the 
thyroid  cartilage.  It  might  at  first  be  mistaken  for  a  retropharyngeal 
abscess,  but  the  latter  is  not  movable. 

The  treatment  is  removal  by  an  operation,  the  tumor  to  be  ap- 
proached as  in  a  low  lateral  pharyngotomy.  If  there  is  any  suspicion 
that  there  is  a  deficiency  of  thyroid  in  the  normal  position,  the  tumor 
should  not  be  removed,  but  displaced  with  an  intact  blood  supply  in  a 
part  of  the  neck  where  it  will  not  cause  obstruction. 


TUMORS  OF  THE  PHARYNX.  623 

Busch  has  called  attention  to  other  benign  retropharyngeal  tumors, 
fibromata,  enchondromata,  and  mixed  tumors.  They  belong  to  the  con- 
nective tissue  group,  are  well  encapsulated,  easily  enucleated,  and  bear 
some  resemblance  to  the  adenomata  of  the  velum  and  palate.  Unless 
ulcerated,  they  cause  symptoms  only  from  their  size.  If  very  freely 
movable  and  their  mucous  covering  is  thin,  they  can  be  removed 
through  the  mouth,  but  otherwise  they  should  be  approached  from  the 
outside.  Extrapharyngeal  malignant  tumors  can  press  upon  or  involve 
the  pharynx,  and  we  have  seen  swallowing  almost  precluded  from 
enlargement  of  the  lymph  nodes  in  Hodgkin's  disease. 

MALIGNANT  TUMORS  OF  THE  PHARYNX. 

The  nasal  and  oral  portions  of  the  pharynx  are  much  more  com- 
monly the  seats  of  malignant  disease  than  is  the  hypopharynx.  The 
most  common  tumor  of  the  pharynx  is  carcinoma,  and  except  when 
due  to  extension  from  the  tongue,  it  is  usually  of  the  medullary  variety 
It  originates  most  commonly  in  the  neighborhood  of  the  tonsil,  but  may 
spread  rapidly.  Here,  as  well  as  elsewhere,  carcinoma  tends  to  ulcerate 
early,  does  not  attain  the  size  to  which  sarcoma  grows,  and  early 
affects  the  lymph  nodes.  In  this  way  they  may  often  be  differentiated 
clinically.  When  seen  early,  they  may  be  removed,  and  a  radical  oper- 
ation done  upon  the  regional  lymph  nodes. 

Lymphosarcomata  may  develop  from  either  the  faucial  or  pharyn- 
geal tonsil,  or  from  any  of  the  collections  of  lymphoid  tissue  of  the 
pharynx.  Stork  describes  their  appearance  as  an  enlargement  that  at 
first  cannot  be  distinguished  from  ordinary  hypertrophy,  unless  per- 
haps it  is  somewhat  whiter  and  more  nodular.  With  this  there  may  be 
a  pale,  somewhat  hard,  and  edematous  thickening  of  the  neighboring 
mucous  membrane.  The  tumor  may  attain  considerable  size,  but  be- 
fore it  does  so,  neighboring  and  distant  lymphatic  infections  become 
evident.  The  general  picture  assumes  that  of  pseudoleucemia.  Death 
from  this  type  of  tumor,  like  that  from  carcinoma,  is  very  painful. 
Unless  seen  very  early,  treatment  is  of  little  avail.  When  seen  early, 
a  free  excision  of  the  tumor  and  of  the  neighboring  lymphatics  should 
be  made. 

Sarcomata,  round  and  spindle  cell,  are  of  more  frequent  occurrence 
than  lymphosarcomata.  They  present  the  usual  characteristics  of  sar- 
coma, especially  considerable  growth  without  ulceration.  They  rarely 
affect  the  lymph  nodes,  but  it  is  very  common  to  find  the  latter  en- 
larged from  inflammatory  irritation. 

The  treatment  is  excision,  if  the  tumor  is  still  accessible,  and 
possibly  the  use  of  Coley's  toxins.  Some  brilliant  results  have  been 
claimed  for  both  radium  and  the  x-ray,  but  we  are  not  ready  to  express 
an  opinion  in  regard  to  their  value. 


624  SURGERY  OF- THE  MOUTH  AND  JAWS. 

In  the  hypopharynx  both  carcinoma  and  sarcoma  occur,  but  they 
are  rare  and  when  they  arise  low  down  are  usually  difficult  of  diagnosis. 
If,  in  making  the  inspection  with  a  laryngoscopic  mirror,  the  larynx  is 
drawn  forward,  the  tumor  may  become  evident.  A  pharyngoscopic 
examination  would  reveal  such  a  growth  when  present.  Kiimmel 
warns  against  the  passage  of  a  bougie,  and  claims  that  there  is  no 
circumstance  under  which  the  pharynx  is  more  easily  perforated. 

Malignant  tumors  in  this  situation,  unless  seen  very  early,  promise 
little  with  operation.  X-ray,  radium,  and  toxins  may  be  tried.  Laryn- 
gotomy  and  gastrotomy  may  be  done  when  the  occasion  arises,  but  as 
Kiimmel  states,  the  best  treatment  is  the  continuous  use  of  morphin. 

PHARYNGOTOMY. 

Operative  invasion  of  the  pharynx  may  be  necessitated  by  cica- 
tricial contraction,  imbedded  foreign  bodies,  and  new  growths — the 
last  being  the  most  common  reason.  Pharyngeal  constrictions  have 
been  considered  previously.  Except  in  operations  in  the  nasopharynx, 
it  is  safer  to  do  a  preliminary  tracheotomy  or  laryngotomy  and  to  pack 
the  lower  part  of  the  pharynx.  When  the  pharynx  is  to  be  laid  widely 
open,  it  may  be  advisable  to  put  the  packing  in  the  opening  of  the 
larynx  after  painting  the  entrance  with  cocain.  In  choosing  the  po- 
sition on  the  operating  table,  the  same  considerations  hold  as  in  oper- 
ating on  the  tongue  (see  page  581). 

In  carcinoma,  lymphosarcoma,  and  some  of  the  sarcomata  the  re- 
gional lymphatics  should  be  removed  (see  page  603).  Kiimmel  gives 
the  location  of  the  lymphatics  primarily  related  to  various  parts  of  the 
pharynx,  as  follows : 

Tumors  arising  above  the  velum  affect  the  retropharyngeal  nodes. 
In  case  of  tumor  originating  in  the  piriform  sinuses,  the  aryepiglottic 
fold,  and  the  posterior  wall  of  the  larynx,  and  consequently  the  anterior 
wall  of  the  hypopharynx,  the  glands  situated  between  the  superior  bor- 
der of  the  thyroid  cartilage  and  the  hyoid  bone  are  first  affected. 
Later,  all  of  the  deep  glands  of  the  neck  are  affected. 

As  with  carcinoma  of  the  tongue,  however,  it  is  better  to  remove  all 
of  the  lymphatics  en  masse,  including  the  whole  of  the  deep  cervical 
chain.  When  possible,  it  is  preferable  to  do  the  operation  in  two 
stages,  as  in  operating  on  the  tongue,  but  in  external  operations 
through  the  neck,  the  removal  of  the  growth  and  of  the  lymph  nodes 
is  usually  done  at  one  operation. 

Intraoral  Removal  of  a  Malignant  Growth  of  the  Tonsil  and 
Velum — Operation  Through  the  Mouth. — The  following  operation 
is  taken  from  Jacobson: 

This  method  can  only  be  made  use  of:  (a)  in  a  very  early  stage  of  ton- 
sillar new  growths,  when  there  is  no  evidence  of  grandular  enlargement;  or 


TUMORS  OF  THE  PHARYNX.  625 

(b)  when  epithelioma  of  the  tonsil  coexists  with  a  similar  condition  of  the 
tongue. 

If  the  following  operation  seems  somewhat  severe,  the  infiltrating  ten- 
dency of  growths  here  must  be  remembered. 

In  most  cases  the  surgeon  will  do  well  to  avail  himself  of  the  help  given 
by  the  following  preliminary  steps:  (1)  laryngotomy  and  plugging  the 
fauces  with  a  sponge,  placing  a  temporary  loop  around  the  common  carotid; 
(2)  slitting  the  cheek. 

The  patient's  head  being  suitably  raised  and  supported  in  a  good  light, 
the  cheek  on  the  afifected  side  is  divided  from  the  angle  of  the  mouth  to  the 
masseter,  and  the  two  ends  of  the  facial  artery  tied  and  twisted.  The  mouth 
is  now  kept  widely  open  by  a  gag  inserted  on  the  opposite  side,  the  tongue 
drawn  out  of  the  mouth,  and  the  masseter  pulled  backward  by  a  retractor. 
As  much  room  and  light  as  possible  being  thus  obtained,  the  surgeon  divides 
the  soft  palate  first  in  the  middle  line,  and  then  from  within  outward  with 
scissors;  he  next,  either  with  the  same  instrument  or  with  a  blunt  dissector 
and  his  nail,  dissects  around  and  carefully  enucleates  the  tonsil  with  the  pil- 
lars. The  whole  operation  should  be  deliberately  carried  out,  the  surgeon 
cutting  wide  of  the  growth  and  encroaching  on  the  tongue,  etc.,  if  necessary. 
Bleeding  will  be  best  arrested  by  temporary  forceps  pressure  and  firm 
sponge  pressure. 

Where  the  growth  is  at  all  cauliflower  in  its  prominence,  the  chief  part 
may  be  first  removed  with  a  heated  wire  or  with  the  Paquelin  cautery,  so  as 
to  get  more  room  in  dealing  with  the  base.  And  if  the  surgeon  so  prefers, 
he  may  do  the  whole  operation  with  cautery  instead  of  scissors.  In  any 
case  the  cautery  must  be  used  at  a  dull-red  heat  only,  for  fear  of  hemor- 
rhage. The  surgeon  must  be  prepared  for  its  leaving  indurated  tissues 
which  may  simulate  deposits  of  growth,  and  for  the  tendency  of  the  instru- 
ment, as  it  is  quickly  cooled  down  by  its  contact  with  succulent  tissue,  to 
stick  to  them.  A  little  additional  heat  frees  it  at  once,  far  more  satisfac- 
torily than  pulling  it  away.  I  prefer  to  limit  the  cautery,  if  used,  to  searing 
thoroughly  the  surface  of  the  wound. 

Mr.  Butlin  points  out  that  some  of  the  new  growths  met  with  here  are 
so  easily  separable,  so  circumscribed,  if  not  encapsuled,  that  there  is  not  the 
least  difficulty  in  shelling  them  out. 

High  Lateral  Pharyngotomy. — This  and  the  low  lateral  phar- 
yngotomy  should  be  preceded  by  laryngotomy.  If  the  growth  is  not 
movable  on  the  pharyngeal  wall,  or  if  situated  too  low  down  to  be 
reached  from  within  the  mouth,  then  the  operation  of  von  Mikulicz  may 
be  resorted  to.  It  consists  in  gaining  access  by  the  excision  of  one 
ramus  of  the  jaw.  This  operation  is  susceptible  to  many  modifications, 
but  the  general  principle  is  the  same.  No  deformity  or  impairment  of 
function  results  from  the  excision  of  the  ramus,  and  the  field  is  better 
displayed  than  by  simply  dividing  the  bone.  One  plan  of  doing  this  is 
as  follows: 

The  cheek  is  split  from  the  corner  of  the  mouth  straight  back  to 
the  masseter  muscle.  If  this  does  not  give  sufficient  room,  the  pos- 
terior end  of  the  cheek  cut  is  continued  downward  and  backward  to 


626  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  lower  end  of  the  posterior  border  of  the  jaw.  The  posterior  end 
of  this  cut  severs  all  of  the  tissues  down  to  the  bone.  This  latter  cut 
divides  the  branches  of  the  cervicofacial  division  of  the  seventh 
nerve,  which  leaves  the  lower  lip  and  platysma  muscle  paralyzed  on 
that  side.  This  is  not  a  very  evident  deformity.  With  a  periosteal  ele- 
vator the  masseter  muscle  is  raised  from  the  outer  surface  of  the 
ramus  until  the  neck  of  the  condyle  is  exposed.  With  a  wire  saw  the 
jaw  is  cut  through  at  the  junction  of  the  body  and  ramus,  the  line  of 
the  cut  running  downward  and  backward.  The  ramus  is  tilted  out- 
ward, freed  subperiosteally  from  the  structures  on  its  inner  surface, 
and  finally  twisted  out  of  the  socket.  The  inferior  dental  artery  and 
nerve  will  be  cut  or  torn,  and  the  former  may  have  to  be  caught  and 
twisted.  It  is  easier  to  cut  the  coronoid  process  with  forceps  than 
to  separate  the  tendon  of  the  temporal  muscle. 

The  removal  of  the  ramus  leaves  the  outer  surface  of  the  internal 
pterygoid  muscle  exposed,  upon  which  lie  the  lingual  and  mylohyoid 
nerves.  The  tonsil  lies  upon  the  mesial  surface  of  the  lower  part  of 
this  muscle,  separated  from  it  by  the  muscular  wall  of  the  pharynx 
and  the  styloglossus  muscle.  The  internal  pterygoid  may  be  drawn 
forward  or  backward,  or  it  may  be  cut  transversely,  or  excised  with 
a  growth.  In  making  a  block  excision,  it  is  to  be  remembered  that 
the  hypoglossal  nerve  skirts  the  pharynx  at  the  level  of  the  lower 
border  of  the  jaw,  when  the  latter  is  in  its  normal  position.  Moreover, 
the  internal  carotid  artery  lies  l^A  centimeters  behind  the  tonsil.  If 
the  excision  is  to  be  extensive,  especially  in  the  posterior  and  upper 
part  of  the  pharynx,  it  is  a  safe  plan  to  put  a  provisional  ligature 
around  the  common  carotid  that  can  be  drawn  tight  if  needed. 

In  the  original  Mikulicz  operation,  the  incision  extends  from  the 
mastoid  process  downward  and  forward  to  the  greater  cornu  of  the 
hyoid.  The  ramus  of  the  jaw  is  exposed  on  its  inner  and  outer  sur- 
faces without  cutting  the  facial  nerve.  After  excising  the  ramus,  the 
jaw  is  drawn  aside,  the  masseter  and  internal  pterygoid  muscles  are 
drawn  forward,  and  the  digastric  and  stylohyoid  are  drawn  down- 
ward and  backward.  Then  the  surface  of  the  wound  corresponds 
very  closely  with  the  region  of  the  tonsil.  When  the  lateral  wall  of 
the  pharynx  is  divided,  access  is  obtained  to  the  palate  tonsil,  base  of 
the  tongue,  and  pharyngeal  wall.  By  dividing  the  stylohyoid  and  di- 
gastric muscles  and  hypoglossal  nerve,  entrance  to  the  larynx  is  made 
accessible.  The  splitting  of  the  cheeks  gives  the  operator  a  more 
forward  view.  If  the  procedure  first  described  does  not  give  a  suffi- 
ciently low  exposure,  the  incision  can  be  carried  below  the  angle  of  the 
jaw  to  the  middle  of  the  upper  border  of  the  hyoid  bone. 

In  opening  the  pharynx  in  this  region,  the  following  structures  from 


TUMORS  OF  THE  PHARYNX.  627 

above-  downward  will  be  encountered :  the  stylohyoid  and  digastric 
muscles,  the  hypoglossal  nerve,  hyoglossus  muscle,  and  lingual  artery. 
In  repairing  the  wound,  the  divided  structures  are  sutured  wherever 
possible.  If  the  defect  in  the  pharyngeal  wall  is  not  too  great,  it  is 
closed  with  chromic  gut,  but  the  wound  in  the  neck  is  either  left  open 
and  packed,  or  it  is  closed  with  very  free  drainage.  For  a  low  ex- 
posure of  the  pharynx  von  Langenbeck's  lateral  pharyngotomy  is  more 
appropriate. 

Low  Lateral  Pharyngotomy. — The  incision  is  made  along  the 
anterior  border  of  the  sternomastoid  from  the  mastoid  process  to 
below  the  cricoid.  The  platysma  muscle  and  deep  fascia  are  cut 
through.  After  separating  the  tissues  and  drawing  the  carotid  sheath 
backward,  the  lingual  and  superior  thyroid  arteries  and  the  several 
■reins  are  doubly  ligated  and  divided.  By  means  of  a  curved  steel 
sound  passed  into  the  pharynx  through  the  mouth,  the  lateral  pharyn- 
geal wall  is  pushed  into  the  wound  and  incised.  It  is  not  practical  to 
pack  the  pharynx  until  it  has  been  opened  and  explored.  The  edges 
of  the  wound  are  caught  with  clamps,  and  the  finger  is  passed  into  the 
pharynx,  the  wall  of  which  can  then  be  divided  as  far  as  necessary. 
Just  below  the  jaw  the  visual  field  is  small.  It  can  be  enlarged  by 
extending  the  incision  transversely  forward  above  the  hyoid  bone, 
which  renders  the  area  of  the  piriform  sinuses  very  accessible. 

In  low  lateral  pharyngotomy  both  the  external  and  internal  branches 
of  the  superior  laryngeal  nerve  will  probably  be  divided.  The  internal 
branch  passes  forward  deep  to  the  external  carotid  artery,  crossing  the 
outer  surface  of  the  posterior  part  of  the  greater  cornu  of  the  hyoid 
from  behind  downward  and  outward.  Cutting  this  nerve  may  cause 
severe  shock,  and  it  has  been  advised  to  block  it  with  cocain  before 
dividing.  The  nerve  is  small,  and  it  might  be  painted  with  a  20  per 
cent  solution  of  novocain. 

In  approaching  a  cancerous  growth  by  a  lateral  pharyngotomy,  the 
regional  lymphatics  should  be  removed  before  the  pharynx  is  opened. 
If  the  condition  of  the  patient  did  not  warrant  a  continuance  of  the 
operation  after  the  pharynx  was  exposed,  the  edges  of  the  skin  wound 
might  be  sutured  to  the  pharynx  along  the  line  of  the  proposed  pharyn- 
geal incision,  or  the  lateral  spaces  left  after  removing  the  nodes 
might  be  obliterated  with  buried  catgut  sutures,  the  wound  over  the 
pharynx  being  dressed  open.  At  a  subsequent  date  the  pharynx  could 
be  opened,  and  the  operation  completed. 

In  making  repair,  if  possible,  the  pharyngeal  wound  should  be 
closed,  but  it  is  advised  to  pack  the  external  wound.  Von  Bergmann 
has  suggested  suturing  the  pharyngeal  wall  to  the  skin.  This  has  two 
immediate  advantages :  (a)  it  allows  free  escape  of  the  secretions,  and 


628  SURGERY  OF  THE  MOUTH  AND  JAWS. 

(b)  the  patient  can  be  conveniently  fed  by  a  catheter  passed  through 
the  wound.  Later  an  operation  might  have  to  be  done  to  close  the 
pharyngeal  fistula.  If  the  pharyngeal  wound  is  to  be  sutured,  Kiimmel 
suggests  the  passing  of  a  soft  catheter  through  the  nose  down  to  a 
point  below  the  pharyngeal  wound,  holding  it  there  with  absorbable 
catgut  suture.  Through  this  tube  the  patient  can  be  fed.  Preliminary 
gastrostomy  may  be  done,  but  it  is  an  extra  and  we  believe  unnecessary 
operation.  In  a  case  of  ours,  an  infection  at  the  gastrostomy  wound 
so  long  delayed  the  real  operation  as  to  render  it  evidently  useless. 

The  tracheal  tube  should  be  left  in  place  until  all  active  inflamma- 
tion has  subsided.  Kiimmel  cites  a  case  of  his,  in  which  tracheotomy 
was  not  performed,  the  patient  dying  of  edema  of  the  glottis  fourteen 
days  after  operation,  before  tracheotomy  could  be  done. 

The  operations  of  approaching  the  pharynx  from  the  front  by  a 
transverse  suprahyoid  or  infrahyoid  pharyngotomy  have  fallen  some- 
what in  disrepute  for  two  reasons  :  ( 1 )  they  do  not  furnish  free  access ; 
and  (2)  they  are  more  apt  to  be  followed  by  phlegmonous  inflamma- 
tion of  the  neck.  The  infrahyoid  pharyngotomy  has  the  further  dis- 
advantage that  on  one  side  the  incision  must  not  extend  closer  than  1.5 
centimeters  to  the  extremity  of  the  hyoid  bone.  Otherwise  both  in- 
ternal laryngeal  nerves  might  be  cut,  causing  anesthesia  of  the  larynx, 
and  predisposing  to  pneumonia. 

Kocher  recommends  transverse  pharyngotomy  for  reaching  the 
neighborhood  of  the  epiglottis  and  the  base  of  the  tongue.  If  a  trans- 
verse pharyngotomy  is  performed,  either  primarily  or  in  conjunction 
with  a  lateral  approach,  all  but  the  deepest  part  of  the  wound  should 
be  left  opened  and  packed.  (For  exposure  of  the  nasopharynx  b\ 
splitting  the  velum,  see  page  288.) 


CHAPTER  XLII. 

LIGATION  AND  TEMPORARY  CONSTRICTION  OF 
THE  ARTERIES. 

In  all  extensive  operations  about  the  mouth  the  prophylactic  con- 
trol of  hemorrhage  is  important,  both  on  account  of  the  saving  of  blood 
and  because  it  lessens  the  danger  of  aspiration  pneumonia. 

The  permanent  ligation  of  the  common  carotid  artery  is  an  opera- 
tion that  should  never  be  done  without  necessity.  In  young  subjects 
with  soft  arteries  it  is  supposed  to  be  free  from  danger,  but  we  have 
seen  very  severe,  though  not  permanent,  brain  disturbance  result  from 
the  ligation  of  the  common  carotid  artery  in  a  boy  nineteen  years  old. 
In  older  persons  it  is  a  procedure  fraught  with  the  gravest  dangers 
both  to  brain  function  and  to  life,  and  as  Kocher  expresses  it :  "ligature 
of  the  common  carotid  artery  in  an  old  man  with  arterial  sclerosis  is 
equivalent  to  a  death  sentence." 

In  the  days  when  every  wound  was  expected  to  become  infected 
it  was  customary  to  ligate  arteries  only  at  a  distance  from  a  large 
branch  or  trunk.  This  was  done  with  the  idea  that  when  a  long  clot 
could  form  in  the  vessel  there  was  less  likelihood  of  secondary  hem- 
orrhage occurring  from  ulceration  at  the  site  of  ligature.  This  was 
a  common  cause  of  death  in  those  days  after  the  ligation  of  large 
vessels.  The  fact  that  the  external  carotid  gives  off  many  large  vessels 
within  a  centimeter  or  two  of  its  origin  deterred  the  earlier  surgeons 
from  ligating  it.  With  clean  wounds  the  danger  of  secondary  hem- 
orrhage is  eliminated.  The  death  rate  from  the  ligation  of  the  common 
carotid  is  between  10  and  20  per  cent,  while  brain  disturbances  occur  in 
about  25  per  cent.  For  prophylactic  purposes  the  choice  lies  chiefly  be- 
tween ligation  of  the  external  carotid  and  temporary  compression  of 
the  common  artery,  but  in  certain  limited  operations  on  the  face  or 
tongue  the  facial  or  the  lingual  artery  may  be  separately  controlled. 
Even  the  control  of  one  external  or  one  common  carotid  may  not  suffi- 
ciently limit  the  peripheral  bleeding,  on  account  of  the  free  anastomosis 
between  the  vessels.  This  is  especially  liable  to  be  the  case  when  the 
arteries  are  dilated  from  sclerosis.  In  these  cases  we  have  introduced 
the  procedure  of  ligating  the  external  carotid  on  one  side  and  tempo- 
rarily compressing  the  common  carotid  on  the  other.  This,  as  a  rule, 
gives  an  almost  bloodless  field.     In  tying  or  compressing  an  artery,  the 

629 


630  SURGERY  OF  THE  MOUTH  AND  JAWS. 

ligature  should  be  applied  with  just  sufficient  pressure  to  occlude  the 
vessel,  but  none  of  its  coats  should  be  damaged. 

CORONARY  ARTERIES. 

These  are  never  tied  except  at  a  wound,  but  may  be  conveniently 
temporarily  compressed  by  forceps  that  grasp  the  full  thickness  of  the 
lip.  The  forceps  are  not  to  be  locked,  but  may  be  held  in  position  by 
winding  a  silk  ligature  around  the  handles. 

TEMPORAL  ARTERY. 

This  artery  is  practically  never  tied  except  in  an  open  wound,  but 
it  may  be  compressed  by  surrounding  it  with  a  silk  ligature,  without 
making  an  incision,  by  passing  a  full-curved  or  half-circle  needle  around 
it  down  to  the  zygoma  immediately  in  front  of  the  ear. 

FACIAL  ARTERY. 

This  artery  may  be  temporarily  compressed  by  passing  a  ligature 
around  it  in  the  same  manner  as  the  temporal.  The  ligature  must  be 
strong,  as  it  includes  a  quantity  of  tissue  besides  the  artery,  and  must 
be  tied  tightly.  The  artery  crosses  and  lies  close  to  the  lower  border 
of  the  body  of  the  lower  jaw  at  the  anterior  border  of  the  masseter 
muscle.  It  may  be  ligated  at  this  site  by  making  an  incision  2  centi- 
meters long,  parallel  to  the  lower  border  of  the  bone.  The  skin,  pla- 
tysma,  and  fascia  are  divided,  and  the  artery  is  exposed  by  drawing 
back  these  structures  with  sharp  hooked  retractors.  The  inframaxillary 
branch  of  the  facial  nerve  lies  below  the  border  of  the  jaw.  The 
artery  is  accompanied  by  the  facial  vein.  (For  ligation  of  the  facial 
artery  at  its  origin,  see  External  Carotid  Artery.) 

LINGUAL  ARTERY. 

In  the  first  and  second  parts  of  its  course  this  artery  bears  a  close 
relationship  to  the  upper  border  of  the  greater  cornu  of  the  hyoid 
bone.  As  a  prophylactic  measure  before  operation  on  the  tongue,  or  to 
control  bleeding  from  the  tongue,  such  as  from  carcinomatous  ulcer- 
ation, it  is  usually  tied  in  the  second  part  of  its  course.  An  incision 
is  made  along  the  upper  border  of  the  greater  cornu  from  just  behind 
the  angle  of  the  jaw  to  the  body  of  the  hyoid  bone.  This  incision 
extends  through  the  skin,  platysma,  and  fascia;  then  these  structures 
are  forcibly  retracted. 

The  facial  vein  often  passes  downward  and  backward  across  the 
exposed  field,  and  it  may  be  convenient  to  doubly  catch  and  cut  and 
ligate  it.  The  lower  border  of  the  submaxillary  salivary  gland  appears 
beneath  the  upper  border  of  the  wound.     This  is  to  be  freed  and  drawn 


LIGATION  OF  THE  ARTERIES,  631 

upward  with  a  broad-curved  retractor.  By  this  means  the  triangle, 
formed  by  the  midtendon  of  the  digastric  muscle  below  and  the  hypo- 
glossal nerve  above,  will  be  exposed  just  above  the  hyoid  bone.  .  It  is 
through  this  triangle  that  the  lingual  artery  is  to  be  usually  exposed. 
To  render  this  field  more  accessible,  Kocher  recommends  that  first 
the  hyoid  bone  is  pressed  up  from  the  opposite  side,  and  after  exposing 
the  greater  cornu,  it  is  seized  with  a  sharp  hook  and  drawn  forward. 
In  this  way  the  field  is  made  more  superficial.  From  the  upper  border 
of  the  posterior  end  of  the  greater  cornu,  the  fibers  of  the  hyoglossus 
muscle  are  seen  to  ascend  vertically.  The  hypoglossal  nerve  lies  on  the 
superficial  surface  of  this  muscle,  but  anteriorly  disappears  under  the 
posterior  border  of  the  mylohyoid  muscle.  The  lingual  artery  lies  deep 
to  the  hyoglossus  muscle  in  this  triangle.  It  is  usually  exposed  by 
carefully  cutting  through  this  muscle  in  the  triangle  and  retracting  the 
fibers  as  they  are  cut.  The  artery  rests  upon  the  middle  constrictor 
muscle  of  the  pharynx.  Kocher  exposes  the  artery  by  incising  the  hyo- 
glossus muscle  just  above  the  thickened  posterior  extremity  of  the 
cornu,  behind  the  tendon  of  the  digastric  and  the  stylohyoid  muscle, 
and  below  the  hypoglossal  nerve.  By  so  doing,  he  also  controls  the 
dorsal  branch.  (For  ligation  of  the  lingual  artery  at  its  origin,  see 
External  Carotid  Artery.) 

EXTERNAL  CAROTID  ARTERY. 

To  expose  this,  we  use  Kocher's  normal  incision,  which  runs  from 
the  anterior  part  of  the  apex  of  the  mastoid  process  to  the  body  of  the 
hyoid  bone,  passing  a  finger  breadth  below  and  behind  the  angle  of 
the  jaw.  By  making  this  incision  pass  two  finger  breadths  below  the 
angle,  a  better  exposure  is  obtained.  The  origin  of  the  artery  lies 
under  the  anterior  border  of  the  sternomastoid  muscle  at  the  level  of 
the  upper  border  of  the  thyroid  cartilage.  It  is  much  more  common 
practice  to  run  the  incision  from  the  mastoid  process  to  the  cricoid 
cartilage  along  the  anterior  border  of  the  mastoid  muscle,  but  this  gives 
little  better  exposure  and  leaves  an  unsightly  scar.  The  skin  and  pla- 
tysma  muscle  are  incised,  and  these  tissues  are  forcibly  retracted  with 
sharp  hooked  retractors.  By  this  means  5  centimeters  of  the  anterior 
border  of  the  sternomastoid  muscle  should  be  exposed.  In  the  pos- 
terior part  of  the  wound  the  external  jugular  vein  and  the  great  auricu- 
lar nerve  lie  upon  the  sternomastoid.  The  deep  layer  of  the  cervical 
fascia  is  incised  along  the  anterior  border  of  the  sternomastoid,  the 
latter  being  freed  and  retracted.  The  common  facial  vein  is  seen 
passing  downward  and  backward  over  the  posterior  belly  of  the  di- 
gastric and  stylohyoid  muscles  to  join  the  deep  jugular.  It  lies  super- 
ficial to  the  arteries  and  may  be  retracted  downward,  but  more  room  is 


632  SURGERY  OF  THE  MOUTH  AND  JAWS. 

gained  by  doubly  catching  it  with  forceps,  cutting  and  ligating  it. 
The  origins  of  both  the  external  and  internal  carotid  arteries  are  now 
exposed  (Fig.  414).  The  internal  carotid  lies  posterior  and  slightly 
superficial  to  the  external  carotid,  and  can  usually  be  further  identified 
by  the  fact  that  it  rarely  gives  off  branches.  The  internal  carotid 
artery  occasionally  springs  from  the  arch  of  the  aorta,  or  one  or  more 
branches,  usually  derived  from  the  external  carotid  artery,  may  arise 
from  it.  The  external  carotid  artery  gives  off  in  its  exposed  portion ; 
the  superior  thyroid  artery,  which  runs  forward  and  downward  below 
the  level  of  the  cornu  of  the  hyoid  bone;  the  lingual,  which  runs  above 
the  cornu ;  and  the  facial  and  the  occipital  arteries,  which  run  forward 
and  backward  respectively  at  the  level  at  which  the  hypoglossal  nerve 
crosses  superficial  to  the  external  carotid.  There  is  a  small  sterno- 
mastoid  branch  which  bends  downward  over  the  hypoglossal  nerve, 
while  the  ascending  pharyngeal  lies  deep  to  the  main  trunk  of  the 
external  carotid.  In  passing  a  ligature  around  the  trunk,  the  artery 
must  be  first  carefully  freed  and  then  raised  with  the  aneurysm 
needle  or  blunt  elevator;  otherwise  the  descendens  hypoglossi  nerve, 
which  lies  posterior  and  superficial  to  it,  or  the  superior  laryngeal  nerve, 
which  crosses  beneath  the  artery  at  this  level,  might  be  included  in  the 
ligature.  In  order  to  avoid  the  danger  of  wounding  the  artery  just  at 
the  bifurcation,  we  prefer,  where  possible,  to  pass  the  ligature  between 
the  superior  thyroid  and  the  lingual  arteries,  which  has  the  further 
advantage  of  shutting  off  one  source  of  recurrent  circulation. 

It  is  not  easy  to  place  a  Crile  clamp  on  the  external  carotid  artery, 
but  it  may  be  temporarily  constricted  as  follows :  A  very  fine  piece 
of  elastic  rubber  tubing  or  a  thin  strip  of  dam  is  passed  under  the  artery 
as  a  ligature.  A  silk  ligature  is  laid  lengthwise  on  the  artery,  and  the 
two  ends  of  the  dam  strip  are  crossed  over  the  artery  and  the  ligature 
with  just  the  proper  tension.  The  silk  ligature  is  then  tied  around, 
and  holds  the  two  ends  of  the  dam  where  they  cross  each  other.  To 
release  the  constriction,  the  silk  ligature  can  be  cut  without  endanger- 
ing the  artery.  Usually,  however,  for  prophylactic  control,  one  external 
carotid  is  ligated,  and  a  Crile  clamp  is  applied  to  the  opposite  common 
carotid. 

All  of  the  four  larger  branches,  the  superior  thyroid,  the  lingual, 
the  facial,  and  the  occipital  arteries,  can  be  ligated  separately,  and  the 
continuation  of  the  trunk  can  be  exposed  by  drawing  up  the  muscular 
mass  composed  of  the  stylohyoid  and  the  posterior  belly  of  the  digastric. 
This  is  done  in  Dawbarn's  operation  for  the  starvation  of  malignant 
growths.  The  upper  end  of  the  common  carotid  artery  is  exposed  by 
this  same  incision.  A  provisional  ligature  can  be  placed  around  it,  and 
it  can  be  ligated  here  in  case  of  accident  to  the  origin  of  the  external 


LIGATION  OF  THE  ARTERIES.  633 

carotid,  or  when  hemorrhage  is  due  to  damage  to  the  internal  carotid. 
In  one  case  where  we  were  attempting  to  ligate  the  external  carotid 
in  a  mass  of  scar  resulting  from  a  previous  operation,  the  trunk  tore 
close  to  its  origin,  and  we  were  forced  to  ligate  the  common  artery. 

COMMON  CAROTID  ARTERY. 

The  artery  may  be  conveniently  compressed  against  the  transverse 
process  of  the  sixth  cervical  vertebra  at  the  level  of  the  cricoid  carti- 
lage. For  this  reason,  this  process  is  called  the  carotid  tubercle. 
Pressure  is  applied  by  placing  the  thumb  against  the  side  of  the  cricoid 
cartilage  and  pressing  straight  backward.  It  may  be  ligated  in  its 
upper  part  through  the  incision  just  described,  but  it  is  much  more 
easily  exposed  lower  down  in  its  course.  Opposite  the  cricoid  cartilage 
is  the  site  of  election.  As  with  the  external  artery,  it  is  usually  ex- 
posed by  an  incision  along  the  anterior  border  of  the  sternomastoid, 
but  here,  as  in  exposing  the  external  carotid,  the  transverse  incision  is 
preferable.  The  common  carotid  artery  ascends  in  the  neck  in  a  line 
that  passes  from  the  sternoclavicular  articulation  to  the  angle  of  the 
jaw.  A  transverse  incision  at  least  7  centimeters  long  is  made  at  the 
level  of  the  cricoid  cartilage,  with  its  center  corresponding  to  the 
anterior  border  of  the  sternomastoid  muscle.  The  skin  and  platysma 
are  cut  through  and  drawn  upward  and  downward  with  sharp  hooked 
retractors,  which  exposes  the  sternomastoid  and  sternohyoid  muscles. 
If  the  superficial  cervical  nerve  is  seen  crossing  the  sternomastoid 
transversely,  it  is  to  be  drawn  upward.  The  fascia  is  to  be  divided 
along  the  anterior  border  of  the  sternomastoid,  and  the  latter  is  re- 
tracted, exposing  the  long  slender  belly  of  the  omohyoid  muscle,  which 
here  runs  downward  and  slightly  backward.  The  artery  still  remains 
hidden  by  a  second  layer  of  fascia,  the  carotid  sheath,  and  is  to  be  found 
by  splitting  this  sheath  in  the  angle  between  the  omohyoid  and  the 
sternomastoid.  In  doing  this,  the  descendens  hypoglossi  which  lies 
on  the  sheath  is  to  be  drawn  forward.  On  splitting  the  sheath,  the 
artery  is  exposed.  Posterior  to  it  and  slightly  overlapping  it  is  the  in- 
ternal jugular  vein;  between  these  lies  the  vagus  nerve,  while  the  trunk 
of  the  sympathetic  nerve  lies  deep  to  the  artery.  The  aneurysm  needle 
is  passed  from  behind  forward,  avoiding  these  structures.  In  applying 
a  Crile  clamp  for  temporary  compression,  it  is  well  to  raise  the  artery 
with  an  aneurysm  needle. 


CHAPTER  XLIII. 
'      MOTOR  DERANGEMENT. 

Motor  abnormalities  are  of  two  general  kinds :  paralytic,  and  spas- 
modic. 

PARALYTIC  AFFECTIONS. 

If  the  cortical  cells  in  the  motor  area  of  the  brain,  or  any  of  the 
conducting  paths  between  these  cells  and  the  muscle  they  innervate, 
are  interfered  with,  there  will  be  a  partial  or  complete  paralysis  of  that 
muscle.  This  may  be  due  to  a  destruction  of  or  pressure  upon  the 
motor  cells.  It  may  be  due  to  destruction  of  or  pressure  upon  the 
conducting  paths  within  the  brain;  or  it  may  be  due  to  section  of  or 
pressure  upon  a  peripheral  nerve.  In  any  case  the  result  will  be  the 
same.  Motor  impulses  can  no  longer  reach  the  muscle;  therefore 
voluntary  contractions  are  no  longer  possible.  At  first  such  a  muscle 
can  be  made  to  contract  by  some  local  stimulus.  Later,  however,  if  the 
lesion  is  situated  below  the  motor  nerve  nucleus,  the  muscle  will  de- 
generate. After  complete  division  or  blocking  of  a  motor  nerve, 
atrophy  of  the  muscles  follows  quickly,  and  deformities  are  not  un- 
common. The  latter  may  be  due  either  to  the  unopposed  action  of 
other  m.uscles,  or  to  shortening  of  the  paralyzed  muscle  during  atrophy. 
The  condition  of  the  motor  nerve  of  a  muscle  is  best  determined  by 
electrical  tests. 

Electrical  Tests. — The  faradic  current  stimulates  the  nerves 
directly,  and  the  muscles  only  indirectly.  Therefore,  if  the  nerve  has 
degenerated,  there  will  be  no  response  from  the  faradic  current.  The 
galvanic  current  stimulates  both  the  nerve  and  muscle,  causing  a  con- 
traction as  the  current  is  turned  on,  and  another  as  it  is  cut  off.  Only 
a  very  strong  galvanic  current  will  cause  a  continuous  contraction 
during  the  passage  of  the  current.  In  using  the  galvanic  current, 
begin  with  the  weakest  current  that  will  cause  a  response.  A  large 
electrode  is  applied  to  the  back  of  the  patient,  and  a  small  one  is  used 
for  obtaining  muscle  contractions.^  In  health,  using  the  galvanic  cur- 
rent, the  cathodal  closing  is  first  to  appear — that  is,  when  the  negative 
pole,  the  pole  attached  to  the  zinc  plate  of  the  battery,  is  applied  over 
the  muscle.     A  decidedly  stronger  current  is  required  to  elicit  anodal 


ilf  a  wall  plate  Is  not  available,  about  thirty  ordinary  dry  cells  are  required 
for  making  galvanic  tests.  These  are  connected  in  series  with  a  current  controller. 
One  or  two  cells  are  sufficient  to  drive  the  Induction  coil  for  the  faradic  current. 

(v!4 


MOTOR  DERANGEMENT.  635 

closing  or  opening  contractions  with  the  positive  or  carbon  pole  applied 
over  the  muscle.  The  cathodal  opening  contraction  requires  the 
strongest  current  of  all.  The  contractions  in  health  are  sharp  and 
abrupt.  In  disease  the  reactions  may  be  altered  quantitatively  or 
qualitatively.  In  quantitative  alterations  a  given  current  produces 
greater  or  less  contractions  than  it  would  if  the  nerves  and  muscles 
were  normal.  In  qualitative  alterations  the  given  current  may  pro- 
duce sluggish  contractions,  or  the  anodal  contractions  may  be  more 
readily  elicited  than  the  cathodal  closing  contraction. 

These  changes  depend  upon  the  separation  of  the  motor  nerve  from 
its  nutritive  center.  Within  a  short  time  after  this  separation  has  oc- 
curred, degeneration  takes  place.  The  nerve  first  fails  to  respond  to 
electrical  stimulation,  and  after  a  longer  period  the  muscle  will  no 
longer  respond.  It  is  during  the  period  that  occurs  between  the  de- 
generation of  the  nerve  and  that  of  the  muscle  that  the  characteristic 
reaction,  known  as  the  reaction  of  degeneration,  occurs.  This  includes 
a  series  of  changes  that  may  be  summarized  as  follows:  (1)  with  the 
faradic  current  no  response  can  be  elicited;  (2)  with  the  galvanic 
current  occur  both  quantitative  and  qualitative  changes.  Quantitative 
changes :  The  muscles  will  respond  to  a  weaker  current  than  is  re- 
quired in  health ;  this  is  called  the  irritability  of  weakness.  Quahtative 
changes :  The  contraction  becomes  sluggish,  and  in  most  cases  the 
anodal  closing  contraction  is  obtained  with  a  weaker  current  than  is 
cathodal  closing  contraction.  This  is  less  constant  than  is  the  sluggish- 
ness of  the  contraction.  The  reaction  of  degeneration  is  not  fully 
established  until  about  a  week  after  the  nerve  has  been  severed,  but 
the  nerves  begin  to  lose  their  sensitiveness  about  three  days  after  injury. 
If  the  nerve  cannot  be  repaired,  the  muscles  will  cease  to  respond  to 
the  current  after  two  or  three  years  have  elapsed.  When  the  nerve 
connection  is  effectively  reestablished,  the  reaction  of  nerve  and  muscle 
progressively  returns  to  the  normal.  These  changes,  the  reaction  of 
degeneration,  will  be  present  only  when  the  interruption  in  the  motor 
conducting  path  has  occurred  below  the  lower  motor  nucleus,  thus 
separating  the  muscle  endings  from  the  center  that  exercises  trophic 
influences.  When  the  lesion  is  situated  more  centrally,  there  may  be 
no  change  in  the  electrical  reaction.  In  partial  section  or  incomplete 
nerve  block,  the  trophic  changes  are  absent,  and  paralysis  is  not  com- 
plete. 

Treatment. — If  possible,  the  cause  of  pressure  or  of  damage  to 
the  nerve  should  be  remedied.  If  it  is  found  that  the  normal  con- 
ducting path  will  not  be  reestablished  spontaneously,  or  by  such  peri- 
neuria! operations  as  may  be  indicated,  then,  in  the  case  of  certain  im- 
portant nerves,  resort  to  direct  nerve  suture,  or  nerve  transplantation,  is 


636  SURGERY  OF  THE  MOUTH  AND  JAWS. 

indicated.  In  complete  section  of  a  nerve,  direct  nerve  suture,  grafting, 
or  transplantation  should  be  done  as  soon  as  possible.  It  is  only  when 
the  nature  and  extent  of  the  lesion  is  in  doubt  that  the  operation  is  post- 
poned until  time  has  demonstrated  that  the  lesion  will  not  be  remedied 
spontaneously.  When  a  peripheral  motor  nerve  is  cut  some  place  be- 
low its  motor  nucleus,  the  fibers  distal  to  the  lesion  degenerate.  When 
connection  is  established  between  the  distal  part  of  the  motor  nerve  and 
its  own,  or  some  other,  motor  nucleus,  the  nerve  fibers  grow  downward 
into  the  distal  part  of  the  nerve,  and  function  is  reestablished. 

Trifacial  Nerve. — Besides  carrying  sensations  to  one  half  of  the 
face,  each  fifth  cranial  nerve  carries  motor  fibers  to  the  muscles  of 
mastication.  These  will  be  paralyzed  after  section  of  the  posterior  root 
of  the  Gasserian  ganglion,  and  after  removal  of  the  ganglion,  if  the 
motor  root  is  included.  There  is  usually  a  transient  paralysis,  more 
or  less  complete,  after  injection  of  the  third  division  of  the  fifth  nerve 
with  alcohol. 

Paralysis  of  the  muscles  of  mastication  of  one  side  causes  little 
inconvenience  and  is  not  very  noticeable.  On  palpation  it  will  be 
found  that  the  masseter  or  the  temporal  muscles  either  do  not  contract 
or  contract  less  vigorously  than  those  of  the  uninjured  side.  In 
unilateral  paralysis  the  chin  deviates  toward  the  paralyzed  side 
when  the  mouth  is  widely  open,  owing  to  the  unopposed  action  of 
one  external  pterygoid  muscle.  If  there  were  a  complete  bilateral 
paralysis,  the  lower  jaw  would  hang  down. 

Facial  Nerve. — The  facial,  or  seventh  cranial,  nerve  transmits 
motor  impulse  to  one  half  the  face  and  scalp,  exclusive  of  the  muscle 
that  elevates  the  eyelid,  the  ocular  muscles,  the  muscles  of  the  tongue, 
and  the  muscles  of  mastication.  It  also  supplies  impulse  to  one  of 
the  muscles  of  the  middle  ear,  to  the  stylohyoid,  and  to  the  posterior 
belly  of  the  digastric  muscle.  The  chorda  tympani,  which  carries  the 
sensation  of  taste,  is,  for  a  part  of  its  course,  incorporated  in  the 
seventh  nerve.  The  facial  nerve  runs  along  a  tortuous  course  through 
the  temporal  bone,  and  is  not  infrequently  injured  in  fractures  of  the 
skull. 

Paralysis  of  the  face  may  also  be  caused  by  accidental  injuries  to 
the  nerve,  or  infections  or  growths  along  its  course.  It  may  result 
from  an  intracranial  lesion,  either  in  the  cortical  motor  area,  in  the 
nucleus  of  the  seventh  nerve,  or  along  one  of  the  conducting  paths  to 
or  from  the  nucleus. 

Bell's  palsy  is  a  facial  paralysis  due  to  injury  or  disease  of  the  facial 
nerve.  It  may  be  due  to  traumatism  or  tumor,  but  most  cases  develop 
suddenly  without  injury,  as  a  result  of  exposure  to  cold,  or  to  some 
infection.     Rheumatism  and  gout  are  supposed  to  be  etiological  fac- 


MOTOR  DERANGEMENT.  637 

tors.  In  a  few  cases  in  which  the  nerve  has  been  examined  shortly 
after  paralysis  of  the  latter  kind,  a  degenerative  neuritis  has  been  found. 
This  comes  on  quickly  and  may  be  fully  developed  in  a  few  hours  or 
days.  Paralysis,  due  to  tumors  or  middle  ear  disease,  comes  on  more 
slowly  and  is  usually  not  so  well  defined. 

Symptoms. — The  symptoms  will  vary  with  the  location  and  extent 
of  the  lesion.  A  lesion  situated  in  the  face  area  of  the  cortex,  the 
nucleus  of  the  facial  nerve,  or  the  conducting  path  between  them  will 
cause  a  paralysis  of  the  opposite  side  of  the  face.  Shortly  after  the 
nerve  leaves  its  nucleus  in  the  midbrain,  the  fibers  cross  the  median 
plane  to  be  distributed  to  the  face  on  the  opposite  side.  Lesions  below 
the  point  where  the  nerve  tracts  cross  will  cause  paralysis  of  the  face 
on  the  same  side.  If  a  gross  lesion  is  situated  along  the  path  in  which 
the  facial  and  auditory  nerves  lie  in  close  contact,  it  is  likely  that  both 
nerves  will  be  affected.  If  the  lesion  is  situated  between  the  junction 
of  the  pars  intermedia  and  the  giving  off  of  the  chorda  tympani,  it  is 
probable  there  will  be  loss  of  taste  on  one  half  of  the  body  of  the 
tongue.  The  face  shows  characteristic  changes,  varying  with  the  ex- 
tent of  the  paralysis.  In  a  complete  one-sided  paralysis  there  will  be  a 
smoothing  out  of  the  natural  creases  of  the  forehead,  with  an  inability 
to  raise  or  wrinkle  the  brow,  and  there  will  also  be  a  slight  drop  of  the 
eyebrow  of  that  side,  and  an  inability  to  close  the  eye.  When  an 
attempt  is  made  to  close  the  eye,  the  globe  turns  upward,  and  there  is 
a  slight  movement  of  the  lower  lid.  This  latter  movement  is  probably 
due  to  certain  muscle  fibers  innervated  through  the  sympathetic.  In  a 
paralysis  of  long  standing,  there  may  be  considerable  irritation  of  the 
eye,  due  to  the  inability  to  close  it.  The  buccinator  muscle  will  remain 
flaccid,  and  food  will  collect  in  the  buccal  pouch  on  that  side.  The 
mouth  will  be  drawn  to  the  opposite  side  by  the  unopposed  action  of 
the  opposite  buccinator.  It  will  be  impossible  to  pucker  up  the  mouth. 
There  are  other  evidences  of  the  paralysis  present,  but  these  are  the 
most  noticeable. 

Complete  double  facial  paralysis  is,  at  first  sight,  not  so  noticeable 
as  is  paralysis  of  one  side,  owing  to  the  fact  that  the  mouth  is  not 
distorted.  However,  there  is  a  peculiar  mask-like  appearance  of  the 
face,  which  is  due  to  the  immobility  of  the  muscles  of  expression.  We 
have  seen  one  such  case,  in  the  service  of  Dr.  Schwab,  at  the  City 
Hospital,  which  was  part  of  the  symptom  complex  of  a  general  paral- 
ysis. 

Prognosis. — The  prognosis  of  the  non-traumatic  form,  not  due  to 
a  growth,  is  good,  but  recovery  is  not  always  complete.  Mild  cases 
may  recover  in  a  month,  and  the  usual  duration  is  three  to  five  months. 
In  the  traumatic  form  the  prognosis  will  depend  upon  the  extent  and 


638  SURGERY  OF  THE  MOUTH  AND  JAWS. 

character  of  the  injury.  A  partial  section  of  the  trunk  of  the  nerve 
usually  recovers  spontaneously,  because  the  ends  of  the  divided  fibers 
are  still  held  in  close  proximity.  Complete  recovery  is  still  more  apt 
to  occur  after  contusions.  If,  immediately  after  an  injury  of  the  nerve 
or  one  of  its  branches,  the  paralysis  is  not  complete  in  the  part  supplied 
by  the  injured  branch,  then  there  is  good  reason  to  believe  that  there 
will  be  considerable  spontaneous  recovery. 

The  prognosis  of  a  paralysis  due  to  perineurial  tumors,  or  inflamma- 
tory growths,  will  depend  upon  their  nature  and  accessibility.  The 
prognosis  of  a  paralysis  due  to  a  malignant  growth  is  necessarily  bad. 
Where  the  paralysis  is  due  to  simple  pressure,  recovery  will  usually 
take  place  on  removal  of  the  pressure. 

Treatment. — When  there  is  a  complete  transverse  destruction  of 
the  nerve  sheath,  surgical  repair  may  be  undertaken  immediately,  but 
even  the  history  of  an  injury  does  not  always  preclude  spontaneous 
recovery.  In  non-traumatic  Bell's  paralysis,  as  long  as  the  electric 
excitability  remains  unchanged,  no  local  treatment  is  necessary,  but  it 
is  safer  to  use  massage  or  electricity  to  prevent  atrophy  or  degeneration 
of  the  muscles.  When  the  paralysis  remains  unchanged,  the  question 
of  nerve  repair  or  of  an  anastomosis  of  the  facial  to  some  other  motor 
nerve  arises;  but  the  latter  should  not  be  considered  until  after  six 
months,  and  it  is  better  to  wait  a  year.  Hackenbruch  reports  a  favor- 
able result  by  operation  after  7^  years,  Taylor  after  12  years,  Elsberg 
after  29^^  years. 

Ballance,  of  London,  first  did  facial-accessory  anastomosis  on  the 
human  in  1895.  When  a  nerve  is  cut  in  two,  or  is  subjected  to  consid- 
erable pressure  in  any  part  of  its  course,  the  axis  cylinders  degenerate 
in  the  distal  part  of  the  nerve.  If  the  open  end  of  the  distal  part  of  the 
nerve  sheath,  is  properly  united  directly,  or  even  closely,  to  an  opened 
sheath  of  a  motor  nerve  that  still  retains  its  physiological  and  anatom- 
ical central  connections,  then  the  axis  cylinders  will  grow  downward 
into  the  distal  previously  functionless  part  of  the  sheath.  This  reestab- 
lishes physiological  connection  between  the  end  organs  and  the  central 
nervous  system.  The  object  of  anastomosing  the  distal  part  of  a  para- 
lyzed facial  nerve  with  the  trunk  of  a  neighboring  functional  motor 
nerve  is  that  the  intact  nerve  can  be  made  to  take  over  the  function  of 
the  facial,  and  that  a  more  or  less  satisfactory  innervation  of  facial 
muscles  will  result.  The  spinal  accessory  or  the  hypoglossal  is  the 
nerve  chosen.  Even  when  the  technique  and  healing  are  satisfactory,  the 
results  of  the  operation  cannot  be  ideal.  It  is  necessary  to  educate  the 
cortical  centers  to  take  on  a  new  function  for  which  they  were  not 
intended.  After  a  successful  operation  of  this  kind  the  tone  and  grosser 
movements  of  the  facial  muscles  will  be  restored,  but  not  the  finer 


MOTOR  DERANGEMENT.  639 

movements  of  expression.  Further,  after  uniting  the  facial  to  either 
the  accessory  or  hypoglossal  nerves,  there  are  usually  persistent,  ob- 
jectionable, associated  movements— such  as  grimaces  of  the  face  when 
the  patient  shrugs  his  shoulders  or  moves  his  tongue.  The  younger 
the  patient,  the  better  chance  he  has  of  overcoming  or  lessening 
these  association  movements.  Almost  perfect  results  are  to  be  hoped 
for  after  uniting  the  cut  ends  of  the  trunk  of  the  facial  nerve,  but 
unfortunately  the  lesion  is  often  situated  in  an  inaccessible  part  of  the 
nerve.  On  the  whole,  the  results  of  a  satisfactory  anastomosis  are  so 
much  better  than  the  facial  paralysis  that  this  operation  is  well  worth 
doing. 

Faulty  technique,  or  sepsis  in  the  wound,  greatly  lessens  the  chances 
of  good  result.  In  about  two  thirds  of  the  collected  cases  results  have 
been  rather  satisfactory. 

Operation  of  Facial-Accessory  or  of  Facial-Hypoglossal  Anasto- 
mosis.— ExposuRi^  OF  the;  Trunk  of  the  Facial  Nerve. — An  in- 
cision is  made  along  the  anterior  border  of  the  sternomastoid  mus- 
cle from  2  centimeters  above  the  tip  of  the  mastoid  process  to  the 
upper  level  of  the  thyroid  cartilage,  cutting  through  the  skin  and  super- 
ficial and  deep  cervical  fasciae.  To  expose  the  trunk  of  the  facial  nerve, 
the  parotid  gland  is  drawn  forward,  and  the  sternomastoid  is  drawn 
backward  until  the  stylohyoid  and  posterior  belly  of  the  digastric 
muscles  come  into  view.  If  the  trunk  of  the  nerve  is  not  easily  found, 
the  posterior  surface  of  the  parotid  gland  is  carefully  incised.  The 
lobes  are  separated,  and  a  branch  or  division  of  the  nerve  is  sought 
within  the  gland  substance  near  the  posterior  border.  As  the  nerve 
is  approached,  each  piece  of  tissue  is  pinched  with  a  Halsted  forceps 
before  it  is  cut.  When  the  nerve  trunk  or  a  branch  is  pinched,  there 
is  a  contraction  of  the  muscles  supplied.  In  this  way,  the  nerve  can 
be  safely  approached.  When  the  nerve  is  located,  it  is  followed  back 
to  a  point  as  close  to  its  foramen  of  exit  as  possible,  without  injur- 
ing it. 

Exposure  oe  the  Spinai,  Accessory  Nerve. — This  nerve  enters 
the  deep  surface  of  the  sternomastoid  muscle  3  to  5  centimeters  below 
the  mastoid  process.  The  trunk  lies  directly  below  or  on  the  transverse 
process  of  the  atlas  and  deep  to  the  posterior  belly  of  the  digastric. 
It  is  found  by  turning  back  the  anterior  part  of  the  sternomastoid  and 
seeking  it  where  it  enters  the  deep  surface  of  this  muscle. 

Exposure  of  the  Hypogeossae  Nerve. — The  nerve  is  sought 
where  it  crosses  superficially  to  the  external  carotid  artery  at  the 
origin  of  the   occipital  artery    (Fig.  419). 

Anastomosis. — Sufficient  of  the  facial  and  the  other  nerve  selected 
should  be  exposed  to  make  the  union  without  tension.    As  high  up 


640 


SURGERY  OF  THE  MOUTH  AND  JAWS 


as  is  practical  on  the  facial  nerve,  a  fine,  curved,  eye  needle,  carrying  a 
very  fine  silk  suture,  is  passed  under  the  sheath,  transverse  to  the  long 
axis  of  the  nerve.  The  suture  should  engage  the  sheath  for  one  fourth 
of  the  circumference  of  the  nerve,  but  should  not  penetrate  deeply  into 
the  substance  of  the  nerve.  On  the  opposite  side  of  the  nerve,  at  exactly 
the  same  level  as  the  first,  a  similar  suture  is  placed.  These  are 
fastened  to  the  upper  protective  cloth  with  two  artery  forceps.  At  the 
proposed  site  of  section  of  the  hypoglossal  or  accessory  nerve,  two  more 
sutures  are  placed  in  a  similar  manner.     With  a  pair  of  sharp  scissors 


Fig.  419,  StriKtures  in  relation  to  tlie  facial,  hypoglossal,  and  spinal  areessory 
nerves.  The  digastric  and  stylohyoid  muscles  have  been  separated  to  show  the  hypo- 
glossal nerve,  and  the  parotid  gland  is  turned  forward  to  display  the  facial  nerve.  In 
this  case  the  spinal  accessory  enters  the  sternomastoid  at  a  lower  level  than  usual. 


(he  facial  nerve  is  cut  just  proximal  to  the  sutures,  while  the  accessory 
or  hypoglossal  is  cut  just  distal  to  them.  The  nerves  should  be  cut 
within  a  millimeter  of  the  sutures.  In  doing  this,  the  trunk  may  be 
steadied  by  grasping  the  facial  nerve  proximal  to  the  sutures  and  the 
hypoglossal  or  accessory  distal  to  them.  As  soon  as  the  nerves  are  cut, 
the  two  ends  are  approximated  by  tying  appropriate  sutures.  The 
ends  of  these  sutures  are  not  immediately  cut  short,  but  are  used  to 
hold  up  the  anastomosis,  while  it  is  carefully  examined.  If  at  any 
point  the  sheath  is  turned  in,  or  the  nerve  not  accurately  abutted,  re- 


MOTOR  DERANGEMENT.  641 

inforcing  sutures  of  fine  split  silk  are  placed.  By  this  method  of  sutur- 
ing, the  ends  can  be  immediately  approximated  as  soon  as  the  nerves  are 
cut,  which  is  probably  a  safeguard  against  intraneural  infection.  In 
making  the  anastomosis  between  the  facial  and  the  accessory,  the  latter 
nerve  may  be  brought  superficial  to,  deep  to,  or  through  the  digastric 
and  stylohyoid  muscles.  The  wound  is  closed,  leaving  in  a  small  strip 
of  rubber  dam  drain,  that  does  not  touch  the  nerves,  and  which  is  to 
be  removed  in  twenty-four  hours.  The  two  most  important  points 
about  the  operation  are  asepsis  and  providing  a  sufficient  length  of 
each  nerve  to  allow  of  anastomosis  without  any  tension. 

The  choice  of  the  nerve  to  be  used,  the  hypoglossal  or  the  accessory, 
requires  some  consideration.  The  centers  which  send  impulses 
through  the  hypoglossal  nerve,  normally,  give  rise  to  finer  movements 
than  those  supplying  the  accessory.  It  might,  therefore,  be  surmised 
that  the  hypoglossal  is  better  adapted  for  taking  over  the  functions 
of  the  facial.  On  the  other  hand,  the  loss  of  one  hypoglossal  is  a  much 
more  serious  matter  than  the  loss  of  the  accessory.  If  the  functional 
result  of  the  operation  proved  a  failure,  after  using  the  hypoglossal, 
the  patient  would  be  much  worse  ofif  than  before  the  operation. 

Hypoglossal  Nerve. — If  motor  impulses  are  shut  off  from  one 
half  of  the  tongue,  it  will  deviate  to  the  paralyzed  side  when  pro- 
truded. If  the  paralysis  persists,  that  side  of  the  tongue  will  later 
shrink.  The  motor  supply  of  the  tongue  is  through  the  hypoglossal 
nerve,  which  comes  from  the  hypoglossal  nucleus  in  the  floor  of  the 
fourth  ventricle.  A  section  of  the  nerve  is  not  infrequently  removed  in 
excising  an  infiltrating  growth  in  the  submaxillary  region.  It  might 
also  be  cut  accidentally  in  operations  about  the  upper  part  of  the  carotid 
sheath.  Paralysis  of  half  of  the  tongue  has  resulted  from  pressure 
upon  the  nerve  in  the  anterior  condyloid  foramen,  due  to  caries  of  the 
occipital  bone.  The  nucleus  of  the  hypoglossal  nerve  may  be  involved 
with  others  in  a  lesion  of  the  bulb.  Functional  motor  disturbances  of 
the  tongue  are  not  infrequent. 

SPASMODIC  AFFECTIONS. 

These  may,  in  a  general  way,  be  divided  into  two  kinds:  (1)  those 
that  are  directly  dependent  upon  some  physical  irritation;  and  (3) 
those  that  are  more  or  less  under  the  control  of  the  volition.  An  ex- 
ample of  the  former  is  tetanic  closure  of  the  jaws,  due  to  some  lesion 
along  the  distribution  of  the  fifth  nerve  (page  73).  A  common  example 
of  the  latter  is  facial  tic,  but  this  may  start  with,  or  even  be  dependent 
on,  some  definite  pathological  or  other  irritation. 

Facial  Tic. — This  is  a  motor  disturbance  afifecting,  chiefly,  mus- 
cles supplied  by  the  seventh  nerve,  and  characterized  by  a  set  of  spas- 


642 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


modic  contractions  of  certain  muscles,  recurring  at  more  or  less  regular 
intervals.  There  are  one  or  more  sharp  contractions  of  the  affected 
muscle,  followed  by  a  period  of  relaxation.  When  the  spasm  involves 
a  number  of  groups  of  muscles,  the  spasm  may  start  in  one  set  and 
travel  in  a  more  or  less  regular  sequence  through  the  various  groups 
involved.  The  interval  between  spasms  varies  in  different  patients, 
and  at  different  times  in  the  same  patient.  This  interval  is  somewhat 
under  the  control  of  the  patient,  but  after  holding  it  in  abeyance  for 
some  time,  the  spasms  recur  in  quick  succession. 

It  most  commonly  appears  in  the  zygomatic  and  orbicularis  palpe- 
brarum muscles  of  one  side,  but  may  spread  to  other  groups ;  and  the 


Pig.  420.  Showing  stylomastoid  foramen  from  which  the  facial  nerve  emerges. 
Also  represents  a  needle  penetrating  to  the  foramen.  The  needle  enters  in  front  of  the 
middle  of  the  mastoid  process.  The  internal  jugular  vein  in  the  jugular  fossa  is  to  be 
avoided. 


tongue,   neck,    shoulder,   and   arm   muscles  may  all  become   involved. 
Occasionally  the  spasms  are  painful,  but  this  is  rarely  the  case. 

Facial  tic  seems  frequently  to  have  its  origin  in  some  local  irrita- 
tion, either  pathological,  or  external — such  as  an  uncomfortable  collar — 
but  it  is  looked  upon  as  essentially  a  habit  spasm.  According  to  Head, 
it  develops  only  in  persons  of  a  certain  neurotic  taint  of  mental  habit — ■ 
such  as  persons  who  make  it  a  practice  of  touching  every  other  post 
that  they  pass,  etc.  In  a  few  cases  it  is  evident  that  it  is  mainly  a 
subconscious  voluntary  action.  Such,  for  instance,  was  the  case  of 
a  young  woman  in  whom  the  tic  had  followed  the  moving  of  a  molar 
tooth  for  a  dental  operation.  She  thought  that  the  new  position  of  the 
tooth  was  responsible  for  the  trouble,  and  when  questioned  on  the  sub- 


xAIOTOR  DERANGEMENT.  643 

ject,  she  immediately  had  a  series  of  spasms  of  extreme  degree,  which, 
also,  involved  the  jaw  muscles.  When  her  attention  was  diverted  from 
her  trouble,  there  was  only  an  occasional  twitching  of  the  buccinator. 
As  a  rule,  the  mental  element  is  exhibited  by  the  power  to  hold  the 
spasms  in  abeyance  for  a  certain  time.  Regardless  of  the  nature  of 
the  original  irritant,  after  the  spasms  have  persisted  for  a  length  of 
time,  the  psychic  element  is  the  all-important  factor. 

Prognosis. — In  the  earlier  cases  great  good,  even  cure,  may  result 
from  proper  treatment.  The  old  long-established  cases  are  liable  to 
persist. 

Tre^atme^nt. — A  physical  cause  should  be  sought  and,  if  possible, 
removed,  but  the  treatment  is  a  problem  for  a  neurologist,  rather  than 
for  a  surgeon.  In  some  cases  good  has  resulted  from  temporarily 
blocking  the  facial  nerve,  in  the  hope  that  a  few  months  respite  will 
break  the  habit,  but  after  such  an  operation,  the  surgeon  must  not  be 
surprised  if  the  tic  recurs,  or  appears  in  some  other  set  of  muscles. 

There  are  several  ways  of  blocking  the  nerve.  One  is  to  cut  down- 
ward and  stretch  it.  Another  is  to  inject  a  weak  alcohol  solution,  40  or 
50  per  cent,  around  the  trunk  with  a  hypodermic  needle  (Fig.  420), 
After  these  operations,  the  nerve  is  more  or  less  paralyzed,  but  will  re- 
cover in  nine  months,  or  even  less  time.  Before  doing  such  an  oper- 
ation, the  patient  and  friends  should  be  given  to  understand  the  results 
in  an  indisputable  manner.  Lawsuits  have  arisen  for  lack  of  a  clear 
understanding  on  this  point. 


CHAPTER  XLIV. 

TIC  DOULOUREUX  AND  SPHENOPALATINE 
NEURALGIA. 

The  term  neuralgia  is  one  that  is  somewhat  loosely  applied.  It  is 
generally  used  to  designate  a  recurrent  localized  pain,  that  cannot  be 
accounted  for  by  any  recognizable  lesion.  According  to  our  limited 
knowledge  of  the  subject,  neuralgia  seems  to  be  due  to  pressure,  tox- 
emia, or  malnutrition,  the  last  including  the  lack  of  an  accustomed 
stimulation. 

As  the  fifth  cranial  nerve  carries  all  common  sensations  from  the 
mouth,  teeth,  and  face,  neuralgias  of  the  head  and  face  are  very  com- 
mon, and  clinically  present  several  varieties.  The  pain  may  radiate 
over  the  distribution  of  several  nerves — as  one  that  involves  the  fifth 
cranial  and  several  cervical  nerves — or  it  may  be  confined  to  one  nerve. 

FIFTH  CRANIAL  NERVE. 

This  nerve  carries  both  motor  and  sensory  fibers.  It  supplies  motor 
impulses  to  muscles  of  mastication,  the  mylohyoid  muscle,  the  anterior 
belly  of  the  digastric  muscle,  and  the  tensor  palati  and  tensor  tympani 
muscles.  It  carries  sensory  impulses  from  the  whole  face  and  its  con- 
tained cavities,  the  mouth,  nose,  and  orbits. 

The  sensory  part  of  the  nerve  has  on  its  root,  situated  on  the  inner 
end  of  the  petrous  bone  within  the  skull,  the  Gasserian  ganglion,  which 
is  analogous  to  a  posterior  root  ganglion  of  a  spinal  nerve.  The  motor 
part  has  no  connection  with  the  ganglion,  but  joins  with  the  sensory 
fibers  of  the  third  or  mandibular  division. 

The  sensory  fibers  are  arranged  in  three  groups.  The  first  or 
ophthalmic  division  arises  from  the  innermost  part  of  the  ganglion, 
emerges  from  the  skull  through  the  sphenoidal  fissure,  and  traverses 
the  roof  of  the  orbit.  The  second  or  maxillary  division  arises  from  the 
midpart  of  the  ganglion,  emerges  through  the  foramen  rotundum, 
crosses  the  sphenomaxillary  fossa,  and  traverses  the  floor  of  the  orbit. 
The  third  or  mandibular  division  arises  from  the  outermost  part  of 
the  ganglion,  and  leaves  the  skull  through  the  foramen  ovale.  Before 
any  of  these  divisions  leave  the  skull,  they  send  off  dural  branches. 

There  are  many  conditions  occurring  in  the  mouth,  and  especially 
in  connection  with  the  teeth,  that  demand  surgical  or  dental  treatment 
on  account  of  the  pain  accompanying  them;  and  in  these  the  pain  is 

()44 


TIC  DOULOUREUX.  645 

often  of  a  referred  neuralgic  character.     Many  attacks  of  neuralgia 
will  yield  to  medical  treatment. 

TIC   DOULOUREUX:    MAJOR   NEURALGIA   OF   THE 
FIFTH  CRANIAL  NERVE. 

A  convulsive  chronic  neuralgia  limited  to  the  fifth  nerve  is  designated 
as  a  major  tic,  or  tic  douloureux,  and  this  can  only  be  relieved  by  some 
surgical  procedure  that  blocks  the  conducting  power  of  the  affected 
nerves.  Possibly  a  practical  way  of  putting  it  would  be  to  say  that 
every  persistent  incurable  neuralgia  of  the  fifth  nerve  is  clinically  a 
major  tic  and  should  be  so  treated.  While  no  patient  should  be 
allowed  to  suffer  unnecessarily,  because  his  ailment  does  not  fall  in 
with  our  preconceived  ideas  of  what  constitutes  a  major  tic,  neverthe- 
less it  is  important  that  the  surgeon,  the  consultant,  and  the  dentist  be 
able  to  recognize  the  disease  when  present  and  to  differentiate  it  from 
other  neuralgias  and  extraneural  conditions  that  simulate  it.  Other- 
wise the  patient  may  be  subjected  to  an  unnecessary  operation,  or  the 
surgeon  may  find  himself  embarrassed  by  a  faulty  prognosis.  If  the 
nerve-blocking  operation  is  successfully  done  to  relieve  the  referred 
pain  of  an  unrecognized  malignant  growth,  valuable  time  may  be  lost 
before  some  gross  symptom  calls  attention  to  the  tumor.  When  the 
dentist  fails  to  recognize  a  true  major  tic,  he  is  likely  to  persist  in 
useless  operations  and  extractions,  which  give  his  patient  no  relief  and 
which  may  cause  his  skill  to  be  questioned. 

A  very  slight  acquaintance  with  the  symptoms  of  the  disease  will 
exclude  the  possibility  of  not  recognizing  it  when  present.  The  recog- 
nition of  its  counterfeits  is,  in  most  cases,  quite  as  simple,  but  may  be 
so  difficult  as  to  baffle  the  most  skillful  and  most  painstaking  neu- 
rologist. 

Symptoms. — In  a  carefully  observed  series  of  cases  of  true 
major  tic,  there  were  some  features  common  to  all.  Within  certain 
limits,  the  clinical  picture  in  the  individual  cases  varied  considerably, 
but  by  excluding  from  operation  cases  that  varied  beyond  these  limits, 
we  have  done  very  few  inappropriate  operations.  The  clinical  features 
that  were  common  to  all  of  the  true  cases  that  we  have  observed  are : 

1.  The  neuralgia  is  confined  to  the  distribution  of  one  or  more 
branches  of  the  fifth  nerve  on  the  affected  side.  There  are  cases  which 
appear  to  be  exceptions  to  this  rule,  but  from  the  anesthesia  resulting 
from  injections,  it  was  learned  that  the  distribution  of  this  nerve  varies 
considerably,  the  most  striking  departure  from  the  average  being 
that  the  first  division,  through  the  supraorbital,  may  supply  the  area 
behind  the  ear.  This  purely  local  distribution  of  the  pain  is  in  striking 
contrast  to  the  pain,  which  Sluder  has  described  as  neuralgia  due  to 
an  irritation  of  the  sphenopalatine,   Meckel's,  ganglion.     In  this  the 


646 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


pain  radiates  over  the  distribution  of  the  first  and  second  divisions  of 
the  fifth  nerve,  over  the  occiput,  side  of  the  neck,  and  dow^n  the  arm, 
forearm,  and  hand  (Figs.  421  and  422) .  We  have  very  occasionally  seen 
a  true  tic  douloureux  associated  with  pain  of  some  other  part.    In  one 


_.A 


Fig.    423. 


Fig.   424. 


Figs.  421  and  422  show  the  anesthesia  resulting  from  a  deep  injection  into  the  first 
and  second  division  of  the  fifth  nerve.  Prom  the  anesthesia  it  will  be  seen  that  the 
area  behind  the  ear  is  supplied,  in  this  case,  by  the  first  division  of  the  fifth  nerve, 
which  accounts  for  the  fact  that  the  pain  radiated  behind  the  ear.  This  Is  not  the 
average  distribution. 

Fig.  42.3.  Case  of  woman  65  years  of  age.  (A)  pain  came  on  at  this  point  in 
1905  ;  (B)  pain  came  on  at  this  point  in  March,  1908  ;  (C)  pain  came  on  in  1905  some- 
time after  the  appearance  at  (A)  ;  (D)  touching  the  spot  (D)  would  start  pain  in 
(A  and  B). 

Fig.  424.  Man  .53  years  of  age.  (A)  pain  came  on  in  this  spot  in  1884,  and 
was  somewhat  relieved  by  cutting  the  supraorbital  nerve  in  May,  1908;  (B)  pain  came 
on  in  this  spot  after  cutting  supraorbital  nerve. 

case  there  was  a  pain  in  the  back  of  the  thigh  that  came  on  and  passed 
off  with  the  facial  pain. 

2.  The  pain  in  every  case  came  on  in  a  rather  definite  spot,  from 
which  it  might  radiate  in  various  directions  over  areas  belonging  to 
the  fifth  nerve  of  the  .same  side  (Figs.  423  and  424). 


TIC  DOULOUREUX. 


647 


3.  Whether  the  first  intimation  was  a  severe  pain  or  a  paresthesia 
so  slight  as  to  be  compared  with  the  touch  of  a  feather,  and  whether 
in  the  later  stages  the  patient  had  but  occasional  twinges  or  the  pains 
followed  each  other  so  closely  as  to  destroy  all  rest  and  drive  the  suf- 
ferer almost  to  desperation,  the  pain  was  always,  in  all  stages  of  the 
disease,  paroxysmal. 

If  the  first  pain  was  severe,  the  patient  might  have  thought  that 
he  had  been  struck  or  stung ;  but  severe,  or  almost  imperceptible,  the 
first  pain,  with  but  very  few  exceptions,  lasted  but  a  second  or  a  few 
minutes.  Later  the  pain  returned — that  day  or  the  next,  or  in  a  week, 
month,  or  year,  but  it  returned.  And  the  subsequent  history  is  that  the 
intervals  between  the  pains  shortened,  and  that  the  length  and  intensity 


Fig.    425. 


Fig.    426. 


Fig.  425.  Man  68  years  of  age.  (A)  pain  came  on  in  this  spot  December,  1906; 
(B)    from  May,  1909,  touching  this  spot  caused  exquisite   pain. 

Fig.  426  is  intended  to  show  the  direction  and  distance  that  the  pain  radiated  from 
the  pain  spots.  The  fact  that  the  pain  radiated  behind  the  ear  tended  to  cast  some 
doubt  upon  the  diagnosis  before  the  injection  was  made.  Result  of  two  injections  is 
shown   in   Figs.   421   and   422. 


of  the  individual  twinges  increased  as  time  went  on.     In  one  of  the 
exceptional  cases  referred  to,  the  first  paroxysm  lasted  four  hours. 

To  the  paroxysmal  character  is  later  added  an  irregular  periodicity, 
which  may  be  evidenced  by  the  pain  being  present  on  alternate  days 
— more  frequent  or  more  intense  on  alternate  days — or  present  for 
indefinite  stretches  of  time  that  last  for  weeks  or  months,  alternating 
with  periods  of  comparative  or  complete  freedom.  A  very  marked, 
regular  periodicity,  especially  in  a  recent  case,  is  strong  evidence 
against  but  does  not  absolutely  exclude  the  possibility  of  its  being  a 
true  major  tic.  Such  neuralgias  are  usually  of  the  variety  known  as 
sun  pains,  which  seem  to  be  due  to  some  malarial  or  climatic  influence 
or  sinus  infection.     In  a  very  few  cases  there  has  been  a  continuous  dull 


648  SURGERY  OF  THE  MOUTH  AND  JAWS. 

ache  over  some  part  of  the  nerve,  with  recurring  paroxysms  of  a 
sharper  character. 

4.  When  the  pain  returns,  it  is  in  the  same  spot  in  which  it  first 
appeared,  and  although  it  may  radiate,  the  pain  is  always  sharpest 
in  one  certain  place  that  can  often  be  covered  by  the  end  of  a  lead 
pencil.  Later  other  such  pain  areas  may  develop,  but  they  are  in 
turn  equally  definite  (Figs.  433  to  435) .  After  some  months  or  years  the 
primary  pain  area  may  be  less  severe.  The  pain  may  come  in  sev- 
eral of  these  spots  at  once,  in  one  or  the  other  by  turns,  or  play  from 
one  to  the  other.  The  pain  may  remain  confined  to  the  distribution  of 
the  branch  over  which  it  first  appeared,  or  it  may  involve  other  branches 
or  divisions  of  the  nerve  successively.  The  second  and  third  divisions 
are  the  ones  supposed  to  be  most  commonly  affected,  and  some  ob- 
servers maintain  that  involvement  of  the  first  alone  is  never  a  true 
major  tic. 

5.  The  neuralgia  is  usually  confined  to  one  side,  but  involvement 
of  both  sides  is  not  uncommon. 

6.  The  trunks  and  branches  of  the  affected  nerve  may  or  may  not 
be  tender,  but  in  almost  all  cases  there  are  spots  over  the  distribution 
of  the  nerve,  stimulation  of  which  causes  a  twinge  in  the  pain  area. 
The  touch  of  a  finger,  a  breath  of  cold  air,  in  some  cases  heat,  in 
others  the  taking  of  food  or  liquids  in  the  mouth  or  the  act  of  swal- 
lowing, or  a  sudden  movement  or  jarring — any  or  all  of  these  may 
bring  the  pain.  One  old  lady  could  not  let  a  bright  light  fall  on  the 
eye  on  the  affected  side  without  a  sharp  pain  in  a  spot  to  the  outer 
side  of  the  ala  of  the  nose  (Fig.  433).  A  number  could  not  take  sweet 
or  sour  things,  and  one  suffered  a  supraorbital  pain  whenever  food 
touched  the  velum.  It  is  pitiful  to  observe  the  extremes  to  which 
sufferers  will  resort  to  avoid  the  stimuli  that  they  know  will  produce 
pain.  Some  of  them  will  talk  from,  or  will  take  food  or  drink  into, 
only  one  side  of  the  mouth.  One  patient  would  go  for  days  without 
swallowing  even  water,  and  others  will  not  enter  a  room  until  they  are 
sure  all  windows  are  closed.  Some,  for  months  at  a  time,  will  not 
wash  one  side  of  the  face  or  brush  the  teeth. 

8.  In  the  older  cases,  though  there  is  evidence  of  extreme  pain 
during  the  attack,  the  patient  seems  to  have  become  accustomed  to  it 
and  seldom  makes  an  outcry  or  demonstrative  complaint. 

9.  Contrary  to  the  repeated  statement  that  it  is  essentially  a  disease 
of  middle  or  later  life,  it  appears  in  all  decades  from  the  second  on. 
The  earliest  case  of  ours  was  nineteen  years,  but  in  most  instances 
it  first  appeared  between  forty-five  and  sixty  years. 

10.  This  form  of  neuralgia  is  extremely  stubborn  to  treatment. 
For  a  time  most  of  them  were  influenced  by  medicinal  treatment,  but. 


TIC  DOULOUREUX.  649 

sooner  or  later,  this  seems  to  lose  its  effect.  In  most  cases  of  long 
standing,  one  or  a  number  of  teeth  had  been  extracted,  usually  with 
little  or  no  benefit.  Removal  of  pulp  stones,  abnormal  roots,  mis- 
formed  teeth,  impacted  or  unerupted  teeth,  or  necrosed  bone  had  in 
many  cases  given  temporary  relief,  possibly  for  months ;  but  in  all 
cases  the  pain  returned.  Excision  of  the  accessible  parts  of  the  af- 
fected nerve  trunks  had  given  temporary  relief,  as  had  injections  into 
the  peripheral  portions  of  the  nerves.  But  even  where  the  relief  ob- 
tained lasted  some  years,  the  pain  eventually  returned.  It  is  not  im- 
possible, however,  that  cases,  giving  typical  symptoms  of  major  neu- 
ralgia, have  been  cured  by  some  other  than  surgical  means.  Natu- 
rally, such  cases  are  not  likely  to  come  under  our  direct  observation. 

The  time  the  neuralgia  had  persisted  before  coming  under  obser- 
vation varied  from  two  months  to  thirty  years,  so  that  in  these  cases 
there  had  been  ample  opportunity  for  trying  various  measures. 

The  duration  of  the  disease  is  one  of  the  strongest  points  in  the 
diagnosis;  it  is  the  recent  cases  that  require  most  careful  differentiation. 
Pains  due  to  pulpitis,  neuralgias  due  to  malaria  or  pus  infections,  pain 
due  to  malignant  growths,  or  any  other  acute  cause,  will,  if  observed 
long  enough,  show  some  change  or  characteristic  that  will  differentiate 
it  from  a  true  tic,  or  the  general  health  or  condition  of  the  patient  will 
give  some  clew  to  the  cause.  Except  indirectly,  through  loss  of  sleep 
or  lack  of  food  during  an  acute  exacerbation,  this  disease  affects  the 
general  health  to  a  remarkably  small  degree. 

In  very  few  cases  have  we  observed  trophic  or  functional  changes, 
such  as  anesthesia,  reddening  of  the  skin,  or  lacrymation  from  the  af- 
fected eye  during  the  attack.  In  those  cases  where  there  was  a  motor 
convulsion  of  the  face  or  neck  muscles,  we  were  inclined  to  believe  that 
the  twitching  was  voluntary  though  subconscious. 

Diagnosis. — From  these  observations,  it  seems  logical  to  con- 
clude that  a  paroxysmal  pain,  coming  on  suddenly  in  one  or  several 
spots  over  the  distribution  of  the  fifth  nerve,  returning  persistently  at 
the  same  spot,  whether  or  not  other  similar  pain  spots  later  appear,  and 
not  yielding  to  medicinal  or  surgical  treatment  of  any  associated 
lesions,  is  a  true  major  tic.  The  conclusion  that  no  neuralgia  except 
that  which  exactly  corresponds  to  all  of  these  conditions  can  be  a  major 
tic  is  probably  not  warranted. 

SPHENOPALATINE  NEURALGIA. 

Sluder  has  called  attention  to  a  pain  syndrome,  which  seems  to  be 
due  to  an  irritation  of  the  sphenopalatine  ganglion.  This  form  of 
neuralgia  is  fairly  common  and  should  be  differentiated  from  tic  dou- 
loureux. His  description  of  the  syndrome  is  concise  and  clear,  and  we, 
therefore,  quote  him,  as  follows : 


650  SURGERY  OF  THE  MOUTH  AND  JAWS. 

"When  seen  from  the  beginning,  the  pains  of  postethinoidal  or  sphenoidal 
diseases  have  usually  preceded  the  development  of  the  characteristic  neu- 
ralgia picture.  I  have  also  remarked  that  after  the  neuralgic  manifestations 
^lave  continued  for  some  time  (approximately  four  weeks)  they  begin  to 
run  irregularly,  assuming  the  form  of  migraine,  which  may  persist  even  for 
years,  after  all  local  inflammatory  conditions  have  disappeared. 

"One  of  the  most  striking  manifestations  of  disturbance  in  the  spheno- 
palatine ganglion  is  the  wide  and  characteristic  distribution  of  pain  along 
definite  lines.  These  neuralgic  manifestations  can  be  evoked  by  mechanical 
irritation  of  the  ganglion,  by  the  faradic  current,  and  by  therapeutic  injec- 
tions of  alcohol.  The  neuralgia  is  described  as  a  pain  at  the  root  of  the 
nose,  sometimes  also  in  and  about  the  eye,  taking  in  the  upper  jaw  and 
teeth;  sometimes  also  the  lower  jaw  and  teeth,  and  extending  beneath  the 
zygoma  to  the  ear  to  take  on  the  form  of  earache.  It  is  emphasized  at  the 
mastoid,  but  is  nearly  always  severest  at  a  point  about  two  inches  posterior 
to  the  mastoid,  thence  reaching  backward  by  way  of  the  occiput  and  neck; 
and  it  may  extend  to  the  shoulder  blade  and  shoulder,  and  in  severe  attacks 
to  the  axilla,  arm,  forearm,  hand,  and  fingers.  This  is  the  most  frequent 
picture,  as  I  have  observed  it.  Sometimes  the  patient  complains  also  of  a 
'stiff'  or  'aching'  throat,  without  inflammation;  of  pain,  or  oftener  of  itching, 
in  the  roof  of  the  mouth;  or  of  pain  inside  the  nose. 

"Along  with  the  pain  there  is,  also,  on  the  affected  side,  slight  anesthesia 
of  the  soft  palate,  and  of  the  pharynx  as  far  down  as  the  lower  part  of  the 
tonsil,  and  also  in  the  anterior  lower  part  of  the  nose. 

"In  a  large  percentage  of  cases,  the  neuralgia  is  accompanied  by  motor 
disturbance,  affecting  the  configuration  of  the  soft  palate.  The  palatine 
arch  on  the  affected  side  is  often  higher  than  on  the  well  side,  and  during 
movement,  the  median  raphe  is  deflected  from  the  affected  side.  Taste  is 
usually  less  acute  on  the  dorsum  of  the  affected  side." 

Pathology  and  Etiology. — Little  is  known  of  the  pathology  of 
this  disease.  It  has  been  supposed  to  be  an  ascending  neuritis;  but 
the  symptoms  do  not  correspond  with  those  of  an  ordinary  neuritis, 
and  little  has  been  observed  by  microscopical  examination  of  sections. 

The  etiology  is  but  little  less  obscure.  The  history  of  certain  cases 
of  tic  douloureux  suggests  very  strongly  the  origin  in  some  tooth 
lesion,  but  a  characteristic  of  both  forms  of  neuralgia  is  that  relieving 
the  supposed  exciting  cause  does  not  relieve  the  pain.  It  is  not  im- 
probable that  many  may  be  the  sequelae  of  sinus  disease. 

TREATMENT. 

Once  the  diagnosis  is  established,  resort  should  be  had  to  some 
measure  that  will  block  the  sensory  conduction  of  the  affected  nerves. 
In  tic  douloureux,  at  first  superficial  injections  may  give  relief  for 
many  months ;  but  later  these  lose  their  effect,  and  some  operation  on 
the  proximal  portion  of  the  nerve  is  usually  indicated.  This  will  con- 
sist either  of  cutting  the  nerve,  and  possibly  removing  a  portion,  or  of 
injecting  some  fluid  around  the  trunk  that  will  influence  its  power  of 
conducting  these  abnormal  painful  sensations. 


TIC    DOULOUREUX.  651 

We  know  little  of  the  cause  or  of  the  pathology  of  this  disease. 
But  in  spite  of  the  fact  that  it  is  often  called  a  central  neuralgia,  some 
part  of  the  irritation  must  be  peripheral ;  for,  if  it  were  otherwise,  no 
amount  of  blocking  of  the  peripheral  paths  would  influence  the  pain. 
Not  knowing  what  the  irritation  is,  or  where  it  is  operative,  it  is  rea- 
sonable to  conceive  that  the  closer  to  the  brain  the  block  is  made  the 
more  likely  is  it  to  be  successful  in  curing.  This  is  borne  out  by  clinical 
observation.  The  peripheral  operations  are  the  simpler,  safer,  and 
least  efficient.  The  deeper  operations  require  more  skill  and  give  more 
lasting  relief. 

Injections,  according  to  our  observations,  give  relief  for  as  long 
if  not  for  a  longer  time  than  do  peripheral  nerve  sections  or  avulsions. 
They  cause  less  immediate  disability  and  discomfort  than  cutting  oper- 
ations, and  as  a  rule,  are  regarded  more  kindly  by  the  patient.  There- 
fore, with  the  exception  of  the  nerves  of  the  orbit,  no  description  will 
be  given  of  the  mode  of  making  these  nerve  sections.  Descriptions 
of  these  operations  will  be  found  in  any  textbook  of  surgery,  most 
concise  in  Kocher's  Operative  Surgery. 

In  a  historical  review  of  the  subject  of  nerve  injections.  Otto 
Weiner  states  that  about  1840,  Ryud  used  morphin  and  creosote,  and  in 
1857,  Wood  injected  morphin,  while  Bell  used  atropin.  From  this 
time  on,  almost  everything  from  air  to  chloroform  has  been  advocated. 
The  use  of  ether  and  chloroform,  and  other  irritating  substances  in 
mixed  sensory  and  motor  nerves  had  to  be  abandoned  on  account  of  the 
paralysis  produced;  chloroform,  on  account  of  the  shock;  and  air,  on 
account  of  the  danger  of  air  embolism. 

It  is  difficult  to  say  just  what  is  the  rationale  of  the  injection 
treatment,  but  clinically  it  is  shown  to  be  very  successful.  There  are 
two  distinct  classes  of  fluids  that  are  used  today  for  injections  into  the 
branches  of  the  fifth  nerve.  The  most  popular  of  these  is  alcohol  in 
various  strengths,  with  or  without  other  substances  in  solution.  The 
formula  that  we  have  generally  used  closely  resembles  that  proposed  by 
Patrick,  and  is  as  follows : 

Novocain,  2%. 

Chloroform,  5%. 

Alcohol,  70%. 

Water,  23%. 
For  injections  made  in  the  deep  orbit,  the  quantity  of  chloroform  is  re- 
duced to  2  per  cent. 

In  1869,  Potain  ascribed  benefit  to  the  parenchymatous  injection  of 
water,  and  later,  aqueous  solutions  of  cocain  became  popular.  On 
account  of  the  toxicity  of  cocain,  Schleich  advocated  weaker  solutions. 
Bock  used  tropacocain,  and  Kurzwelly  beta-eucain. 


652  SURGERY  OF  THE  MOUTH  AND  JAWS. 

In  1904,  Lang  made  intraneural  injections  of  physiological  saline 
solution,  and  beta-eucain,  1 :1000.     Weiner  observed  chills  and  fever 
following  the  use  of  physiological  salt  solution,  and  uses  this  solution : 
Sodium  chlorid,         6. 
Calcium  chlorid,  .75 

Water,  1000. 

He  gives  as  his  results:  in  sciatica,  51  cases  wrere  cured,  8  improved;  in 
trifacial  neuralgia,  22  cases  cured,  2  improved,  and  2  not  improved. 
If  the  experience  of  other  operators  supports  Weiner  in  these  results, 
there  can  be  no  question  that  this  milder  fluid  will  supersede  the  alcohol 
and  all  of  its  relatives.  While  it  is  exceedingly  gratifying  to  be  able 
to  relieve  instantly  and  apparently  permanently  the  most  intense  pain 
by  a  deep  alcohol  injection,  every  thinking  man  appreciates  that  it 
cannot  be  done  without  risk,  and  that  it  is  only  the  gravity  of  the  situ- 
ation that  warrants  the  means. 

Patrick  has  abandoned  the  injection  of  the  first  division.  While 
we  personally  have  not  had  any  mishap  of  permanent  nature,  we  have 
known  two  cases  of  blindness  and  one  of  dementia  to  follow  this 
operation.  It  is  possible  that  these  unfortunate  results  were  due  to 
avoidable  errors  in  technic,  but  in  any  larger  series  of  cases  of  deep 
injections  of  the  fifth  nerve  with  any  corrosive  fluid,  there  will  be  a 
certain  number  of  accidents.  An  efficacious  fluid,  the  use  of  which  is 
free  from  danger,  will  go  a  long  way  toward  increasing  the  popularity 
of  this  method  of  treatment. 

Before  any  injection  is  made,  the  skin  should  be  cleansed.  Before 
an  irritating  solution  is  injected,  it  is  better  to  anesthetize  at  least  the 
skin  by  the  injection  of  a  small  quantity  of  ^  to  1  per  cent  solution 
of  novocain,  the  strength  depending  upon  the  quantity  that  is  in- 
jected (Chap.  XLV).  Before  making  a  deep  nerve  injection,  we  have 
made  it  a  practice  with  ordinarily  strong  patients  to  inject  Viso  grain 
of  scopolamin  and  Ve  grain  of  morphin  into  the  arm  four  hours  be- 
fore the  operation,  and  repeating  the  dose  a  half  hour  before  oper- 
ation. This  usually  has  the  effect  of  very  much  reducing  the  pain 
of  the  injection.  In  very  old  persons  one  such  dose  has  had  the  desired 
effect.  Ordinarily  this  is  a  very  painful  operation,  and  only  the 
knowledge  that  it  gives  almost  instantaneous  relief  in  the  great  ma- 
jority of  cases  gives  the  operator  the  heart  to  persist  in  the  careful, 
painstaking  way  that  is  usually  followed  by  success.  We  occasionally 
do  it  under  a  general  anesthetic,  but  this  is  much  less  likely  to  be 
successful. 

The  needle  used  for  anesthetizing  the  skin  may  be  very  fine,  but 
that  used  for  the  nerve  injection  must  be  coarse  and  rather  blunt,  and 
strong  in  proportion  to  the  depth  at  which  the  injections  are  made 


TIC  DOULOUREUX.  653 

(Fig.  427.)  -The  blunt  needle  is  less  apt  to  open  a  vein  and  liberates 
the  fluid  close  to  the  point.  The  injections  may  be  made  into  the 
nerves,  as  they  emerge  from  the  superficial  foramina  of  exit — v\^hich 
might  be  termed  peripheral  injections;  or  they  may  be  made  with  the 
idea  of  attacking  the  nerve  trunks,  just  as  they  emerge  from  the  fora- 
mina that  furnish  their  exit  from  the  cranial  cavity — which  might  be 
termed  deep  injections.  The  former  could  be  considered  minor,  and 
the  latter  major  operations.  There  are  certain  nerves  that  may  be 
attacked  at  intermediate  points. 

Injection  of  the  Peripheral  Branches  of  the  Fifth  Nerve. — For 
the  peripheral  injections  a  coarse  hypodermic  needle  may  be  ground  on 
a  whetstone  till  the  end  is  cut  an  an  angle  of  45°,  or  such  needles  may 
be  obtained  from  the  dental  supply  houses.  The  needle  is  made  to 
penetrate  deeply  into  the  tissues  before  the  fluid  is  liberated.  For 
these  peripheral  injections  a  small  quantity  (^  to  1  cubic  centimeter) 
of  fluid  is  sufficient. 

Besides  the  knowledge  of  the  exact  or  relative  position  of  the 
foramina  of  exit,  two  other  things  are  helpful  in  locating  the  nerve 
trunks:     (1)     the  nerve  trunks  are  sometimes  tender  to  touch;  and 


zist 


Fig.    427.      Needle   used    for   deep   nerve   injections. 


(3)  an  exquisite  pain,  which  radiates  over  the  distribution  of  the 
nerve,  tells  when  it  is  touched  by  the  needle  or  irritating  fluid.  When 
the  injection  fluid  is  of  an  anesthetizing  character,  this  severe  pain 
lasts  but  a  few  minutes  after  the  first  few  drops  are  liberated.  During 
the  progress  of  the  injection,  the  skin,  or  mucous  membrane  over  the 
distribution  of  the  nerve,  should  be  repeatedly  tested  for  anesthesia, 
which,  when  obtained,  assures  the  anatomical  success  of  the  operation. 
The  point  of  the  needle  is  shifted  in  the  tissues  during  the  injection  so 
as  to  distribute  the  fluid  over  a  sufficient  area  to  insure  its  coming  in 
contact  with  the  nerve  and  to  avoid  the  risk  of  placing  the  whole  in- 
jection in  a  vein. 

The  nasal  nerve  can  be  reached,  before  it  leaves  the  orbit  by  the 
anterior  ethmoidal  foramen,  by  inserting  the  needle  at  the  middle  of 
the  inner  wall  of  the  orbit  above  the  inner  canthus.  The  bony  wall 
must  be  followed  closely  to  avoid  the  lacrymal  sac.  The  bone  itself 
is  very  thin,  and  care  must  be  taken  not  to  puncture  it.  The  nerve 
will  be  encountered  at  a  depth  of  from  18  to  22  millimeters  from  the 
bony  ridge  that  can  be  felt  in  the  inner  border  of  the  orbit.  These 
intraorbital  injections  cause  considerable  swelling  of  the  orbital  tissues 


654  SURGERY  OF  THE  MOUTH  AND  JAWS. 

(see  Deep  Injections  of  the  Ophthalmic  or  First  Division  of  the  Fifth 
Nerve,  page  662). 

The  supraorbital  nerve  is  to  be  attacked  at  the  supraorbital  notch, 
rarely  a  foramen,  which  can  be  felt  at  the  junction  of  the  inner  with 
the  outer  two  thirds  of  the  upper  border  of  the  orbit. 

The  supratrochlear  nerve  emerges  from  the  orbit  just  under  the 
inner  end  of  the  supraorbital  ridge.  Just  before  it  emerges,  it  is 
in  close  relation  with  the  periosteum  and  the  tendon  of  the  superior 
oblique  muscle. 

The  infraorbital  nerve  emerges  from  the  infraorbital  foramen,  which 
is  situated  6  millimeters  below  the  middle  of  the  lower  border  of  the 
orbit.  The  foramen  may  possibly  be  felt  with  the  finger,  and  can 
always  be  located  with  the  needle  point. 

The  orbital  branch  of  the  superior  maxillary  nerve  is  given  off 
in  the  floor  of  the  orbit  or  in  the  sphenomaxillary  fissure,  and  finds 
its  exit  by  one  or  two  foramina  situated  near  the  junction  of  the  floor 
with  the  lateral  wall  of  the  orbit,  4  to  8  millimeters  from  the  border. 
It  divides  into  a  temporal  branch  which  enters  the  temporal  fossa  and 
a  malar  branch  which  appears  on  the  facial  expansion  of  the  malar 
bone.  The  nerve  trunk  might  be  reached  by  inserting  the  needle  just 
where  the  relatively  vertical  outer  wall  emerges  into  the  curved  infra- 
lateral  boundary  of  the  orbit.  The  needle  follows  the  bony  wall  in  a 
downward,  backward,  and  inward  direction  to  a  depth  of  1^  centi- 
meters. The  injection  should  begin  when  the  needle  has  penetrated 
5  millimeters,  and  the  fluid  is  distributed  from  this  point  to  a  depth  of 
15  millimeters,  or  until  an  anesthesia  or  a  paresthesia  over  the  distri- 
bution proclaims  that  the  fluid  has  reached  its  destination.  The  nerve 
is  inconstant  in  its  size,  mode  of  exit,  and  area  of  distribution.  It  may 
be  replaced  by  a  branch  from  the  ophthalmic  division. 

The  auriculotemporal  nerve  may  be  injected  as  it  crosses  the  root 
of  the  zygoma.  It  lies  just  behind  the  temporal  artery,  the  pulsation 
of  which  will  serve  as  a  guide.  This  nerve  lies  in  such  close  relation 
to  the  rather  large  temporal  vein  that  there  might  be  danger  of  the 
fluid  entering  the  latter.  The  excision  of  this  nerve  would  be  safer 
than  injection  with  alcohol. 

The  mental  branch  of  the  inferior  dental  nerve  emerges  through 
the  mental  foramen,  which  opens  on  the  external  surface  of  the  mandi- 
ble below  the  second  bicuspid  tooth.  If  the  lower  teeth  have  not  been 
lost,  the  opening  of  the  foramen  lies  nearer  the  lower  than  the  alveolar 
border  of  the  bone.  If  the  alveolar  process  has  been  absorbed,  the 
opening  will  be  found  at  the  upper  border  of  the  bone. 

The  inferior  dental  nerve,  of  which  the  mental  is  a  branch,  can  be 
reached  just  before  it  enters  the  inferior  dental  canal.     This  injection 


TIC  DOULOUREUX. 


655 


is  more  satisfactorily  made  with  a  strong  needle  5  centimeters  long  or 
longer.  If  the  month  is  opened  fully,  a  triangular  mucus-covered 
space  is  visible  behind  and  above  the  last  lower  molar.  This  space 
covers  the  anterior  border  of  the  internal  pterygoid  muscle,  and  the 
outer  border  of  the  space  is  formed  by  the  anterior  border  of  the  ramus 
of  the  jaw.  These  structures  should  be  identified  with  the  finger.  To 
inject  the  inferior  dental  nerve,  the  needle  pierces  the  mucous  mem- 
brane of  this  triangular  space  near  its  median  border  and  5  millimeters 
above  the  level  of  the  occlusal  surface  of  the  inferior  molars.  It  at 
once  enters  the  substance  of  the  internal  pterygoid  muscle.  The 
syringe  is  held  at  such  an  angle  that  the  barrel  rests  on  the  second 
lower  bicuspid  of  the  opposite  side  (Fig.  428).  The  needle  penetrates 
to  the  bone  and  follows  it  horizontally  backward  to  a  depth  oi  lj4 
centimeters;  and  while  it  is  in  contact  with  the  bone,  the  injection  is 
made,  at  the  same  time  shifting  the  point  to  distribute  the  fluid.  The 
opening  of  the  inferior  dental  canal  is  in  the  middle  of  the  inner  sur- 


Pi£ 


428.     Injection    of    the    mandibular    nerve. 


face  of  the  ramus  at  the  level  of  the  occlusal  surface  of  the  last  molar. 
Above  this  opening  the  inferior  dental  nerve  is  in  contact  with  the 
bone. 

7he  lingual  nerve  lies  in  contact  with  the  ramus  of  the  mandible 
a  little  in  front  of  the  inferior  dental  nerve.  It  may  be  injected  at 
the  same  time  as  the  inferior  dental,  or  it  may  be  reached  by  entering 
the  needle  just  behind  the  last  lower  molar  at  the  level  of  its  neck, 
the  barrel  of  the  syringe  resting  on  the  first  molar  tooth  of  the  opposite 
side.  The  needle  penetrates  about  1  centimeter.  The  point  should  be 
in  contact  with  the  bone  when  the  injection  is  made. 

The  descending  palatine  nerve  enters  the  soft  tissues  of  the  hard 
palate  by  emerging  from  the  posterior  palatine  canal  in  the  sulcus 
between  the  palate  and  the  alveolar  process  opposite  the  last  molar 
tooth.  The  nerve  runs  forward  close  to  the  alveolus  and  can  be  in- 
jected just  as  it  enters  the  palate.  The  lesser  nerves,  that  supply 
sensation  to  the  mucous  membrane  of  the  soft  palate,  emerge  close  to 
the  opening  of  the  posterior  palatine  canal. 


656 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


The  palatine  branch  of  the  nasopalatine  nerve  enters  the  soft  tis- 
sues of  the  hard  palate  from  the  incisive  foramen,  that  hes  behind  the 
incisive  papilla  just  behind  the  incisor  teeth.  It  can  be  injected  by 
entering  the  needle  just  behind  the  interdental  space  in  the  midline 
and  passing  the  point  upward  and  backward  to  the  foramen.  The 
needle  penetrates  about  1  centimeter. 

The  long  buccal  nerve  lies  to  the  inner  side  of  the  coronoid  pro- 
cess. It  may  be  injected  here  with  certainty  only  when  the  nerve 
trunk  is  sufficiently  tender  to  reveal  its  exact  location.  The  injection 
is  made  by  holding  the  mouth  open  with  a  gag,  locating  first  the 
coronoid  process  and  then  the  nerve  trunk  with  the  finger.     The  nerve 


Pis;.   429.      Position  of  patient  and  operator  in   injecting  the  second  or  third  division 
of  the  fifth  nerve. 


lies  between  the  buccinator  muscle  and  the  insertion  of  the  temporal 
muscle. 

The  effect  of  these  superficial  injections  is  more  or  less  satis- 
factory. Very  often  the  first  successful  injection  will  give  relief  for 
months,  but  it  is  our  observation,  from  the  histories  of  a  number  of 
cases  that  had  repeated  superficial  injections,  that,  while  the  first 
injection  may  have  given  relief  for  a  considerable  period  of  time, 
later,  the  time  of  relief  given  shortens  until  at  last  they  are  practically 
ineffective.  The  longest  period  of  relief  that  we  have  known,  follow- 
ing a  superficial  injection,  is  a  year.  When  it  is  demonstrated  that 
superficial  injections  no  longer  give  relief,  then  the  deeper  nerve  trunks 
must  be  attacked.  It  is  our  custom,  when  the  diagnosis  is  established, 
to  at  once  make  the  deep  injections  which  give  a  much  longer  period 


TIC  DOULOUREUX. 


657 


of  immunity.  According  to  our  observations,  the  relief  from  appar- 
ently successful  deep  injections  varies  from  one  year  to  indefinitely. 
Therefore  we  feel  justified  in  the  statement  that,  w^ith  the  possible 
exception  of  the  first  division,  deep  injections  should  be  tried  in  all 
cases  before  the  more  radical  intracranial  operation  is  advised. 

Deep  Injections  of  the  Trunks  of  the  Fifth  Nerve. — Injection 
OF  Third,  or  Mandibular,  Division. — The  needle  enters  5  or  10 
millimeters  below  the  middle  of  the  zygoma  and  half  way  between  the 
posterior  border  of  the  condyle  of  the  jaw  and  the  angle  formed  by 
the  temporal  and  zygomatic  border  of  the  malar  bone  (Fig.  429). 
It  penetrates  to  a  depth  of  40  to  50  millimeters  and  then  comes  in  con- 


Fig.  430.  The  posterior  dotted  line  on  the  pterygoid  process  shows  the  path  fol- 
lowed by  the  point  of  the  needle  in  the  Injection  of  the  third  division,  after  it  has  en- 
countered the  pterygoid  process.  Tlie  anterior  line  shows  one  course  taken  in  reaching 
the  second  division. 


tact  with  the  external  plate  of  the  pterygoid  process.  This  depth 
varies  in  proportion  to  the  width  of  the  skull  and  the  prominence  of 
the  cheek  bones.  The  average  depth  at  which  the  process  will  be 
encountered  is  about  43  millimeters,  and  it  is  not  commonly  over  45 
or  under  40  millimeters,  although  in  a  few  cases  it  may  vary  con- 
siderably beyond  these  limits.  If  the  needle  penetrates  deeper  than 
would  be  expected  from  the  size  and  contour  of  the  skull  without  strik- 
ing the  process,  it  should  be  withdrawn  somewhat  and  thrust  slightly 
upward  and  forward,  for  it  may  have  passed  behind  the  process.  When 
the  bone  of  the  process  is  felt,  the  point  of  the  needle  is  worked  up- 
ward  repeatedly,   withdrawing  slightly,   and  then   reinserting  it,   the 


658 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


point  each  time  coming  in  contact  with  the  bony  plate,  until  the  under 
surface  of  the  great  wing  of  the  sphenoid  is  felt.  This  surface  is 
rather  perpendicular  to  the  pterygoid  process,  and  the  needle  is  felt 
to  slide  obliquely  along  the  bone.  In  this  way  the  sulcus  between  the 
pterygoid  process  and  the  under  surface  of  the  sphenoid  wing  is 
located.  When  this  sulcus  is  recognized,  the  point  of  the  needle  is, 
by  the  same  process  of  withdrawing  and  reinserting,  made  to  step 
backward  until  it  is  felt  to  slip  off  into  the  space  at  the  posterior  border 
of  the  process,  when  it  will  be  right  at  the  foramen  ovale,  which  gives 
exit  to  the  whole  of  the  third  division  of  the  fifth  nerve.     In  working 


Fig.    431.      Skull    showing    o.stcoporosis. 
openings  Into  the  cranial  cavity. 


A,    defect    in    outer    wall    of    antrum.      C, 


the  point  of  the  needle  backward,  it  is  kept  more  in  contact  with  the 
under  surface  of  the  sphenoid  wing  than  with  the  external  plate  of  the 
process.  The  sulcus  between  these  two  is  rounded,  and  the  needle 
must  work  along  the  upper  part  of  the  groove.  Otherwise,  when  the 
posterior  border  of  the  process  is  reached,  the  point  will  be  below  the 
foramen  ovale,  and  a  backward  projection  of  the  external  pterygoid 
plate  might  separate  it  from  the  nerve   (Kig.  430). 

When  from  the  feel  of  the  needle  or  the  sensation  of  the  patient 
it  is  thought  that  the  needle  is  in  contact  with  the  nerve,  the  fluid  is 
liberated  a  few  drops  at  a  time,  the  point  of  the  needle  being  shifted 


TIC  DOULOUREUX.  659 

slightly,  undl  an  anesthesia  and  a  paresthesia  proclaim  the  success  of 
the  injection,  or  until  4  cubic  centimeters  of  the  alcohol  mixture  or 
25  cubic  centimeters  of  Weiner's  fluid  are  liberated.  Special  effort 
should  be  made  to  obtain  an  anesthesia  at  the  site  of  the  pain  spot. 

At  the  time  the  injection  is  made,  the  depth  of  the  needle  point 
should  not  be  more  than  5  millimeters  greater  than  it  was  when  the 
external  pterygoid  plate  was  first  struck.  If  driven  deeper  than  this, 
the  Eustachian  tube,  which  lies  just  internal  to  the  foramen  ovale, 
might  be  injured. 

In  a  skull  that  is  affected  by  osteoporosis  (Fig.  431),  there  may  be 
small  perforations  at  the  base  of  the  pterygoid  process  that  lead  direct 
into  the  middle  cranial  fossa.  Even  if  the  needle  were  to  engage  in 
one  of  these  openings,  it  would  not  penetrate  to  the  dura  without  being 
pushed  to  an  unwarranted  depth.  There  is  another  method  of  reach- 
ing the  third  division  of  the  nerve,  which  consists  in  inserting  the 
needle  intraorally  just  above  the  position  of  the  third  molar  tooth. 
The  point  is  directed  upward  and  backward  and  follows  the  external 
pterygoid  plate  until  the  under  surface  of  the  sphenoid  bone  is  en- 
countered. The  needle  is  then  made  to  step  backward  until  it  drops 
in  the  foramen  ovale.  It  is  much  more  difficult  to  locate  the  foramen 
by  this  technic,  and  it  cannot  be  done  aseptically. 

Sometimes  the  needle  can  be  inserted  through  the  foramen  directly 
into  the  Gasserian  ganglion,  but  the  advantage  of  this  is  somewhat 
doubtful  when  compared  with  the  extra  hazard.  In  one  case  where, 
on  account  of  certain  circumstances,  we  deliberately  injected  the  gan- 
glion through  the  olivary  foramen,  the  operation  was  followed  by  an 
almost  complete  paralysis  of  the  seventh  and  eighth  nerves  of  that 
side.  The  facial  paralysis  was  most  marked  in  the  upper  part.  Within 
six  months  the  facial  paralysis  cleared  off,  but  the  hearing  of  that  side 
had  not  been  restored.  It  is  a  little  difficult  to  explain  this  accident. 
The  centers  of  the  involved  nerves  cannot  be  reached  directly  by  a 
needle  entering  the  cranial  fossa  through  the  foramen  ovale  when  the 
injection  is  made  from  the  external  surface  of  the  face.  It  would  also 
be  impossible  to  directly  injure  the  trunks  of  the  seventh  and  eighth 
nerve  in  this  way.  If  the  alcohol  had  leaked  back  into  the  posterior 
fossa  along  the  root  of  the  fifth  nerve,  then  it  seems  that  the  sixth 
nerve  should  have  been  involved  with  the  seventh  and  eighth.  The 
least  improbable  explanation  would  be  that  the  alcohol  had  followed 
the  great  superficial  petrosal  nerve  to  the  aquseductus  Fallopii. 

Dr.  W.  T.  Coughlin  carried  on  a  series  of  experiments  in  the  ana- 
tomical laboratory  at  Washington  University,  in  which  he  injected  a 
solution  of  methylene  blue  at  the  foramen  ovale  from  the  outer  surface 
of  the  cheek,  as  described  above.     In  the  majority  of  instances  the 


660  SURGERY  OF  THE  MOUTH  AND  JAWS. 

blue  fluid  entered  the  foramen  ovale  and  stained  the  dura  around  the 
entire  Gasserian  ganglion.  On  patients  we  have  seen  an  anesthesia  of 
the  second  or  first  division  follow  an  injection  of  the  third. 

Injection  of  Second  or  Superior  Maxillary  Division. — This 
is  injected  by  inserting  the  needle  below  the  zygoma  at  the  junction  of 
the  anterior  with  its  posterior  two  thirds.  It  may  be  that  the  coro- 
noid  process  of  the  jaw  will  be  encountered,  and  if  this  is  the  case, 
the  mouth  must  be  held  open  with  a  gag  or  by  placing  a  folded  napkin 
or  a  cork  between  the  anterior  teeth  or  gums. 

The  external  pterygoid  plate  is  encountered  at  an  average  depth  of 
43  millimeters,  depending  on  the  size  of  the  skulland  the  prominence 
of  the  zygoma.  In  twenty-two  dried  skulls  the  depth  varied  from  33 
to  50  millimeters.  When  the  external  pterygoid  plate  is  found,  the 
point  of  the  needle  is  made  to  step  upward  and  forward  until  it  is  felt  to 
drop  into  the  sphenomaxillary  fossa,  when  it  will  be  in  close  proximity 
to  the  nerve  sought,  and  also  to  the  sphenopalatine  (Meckel's)  gan- 
glion. In  quite  a  large  number  of  skulls  there  is  a  sharp  outward 
flare  of  the  anterior  border  of  the  external  pterygoid  plate  just  where 
it  is  crossed  by  the  needle.  If  this  is  encountered,  the  needle  must 
be  drawn  sufficiently  to  step  over  this  obstruction.  The  needle,  when 
in  the  fossa,  should  not  have  penetrated  more  than  5  millimeters  deeper 
than  it  was  when  it  first  struck  the  surface  of  the  pterygoid  plate.  On 
entering  the  fossa,  the  needle  is  directly  in  line  with  the  sphenopala- 
tine foramen  of  the  palate  bone  and  could  penetrate  into  the  cavity  of 
the  nose  without  encountering  any  bony  obstruction.  In  this  regard 
the  rule  that  has  been  suggested,  to  insert  the  needle  in  a  direction  up- 
ward and  forward  and  make  the  injection  at  a  depth  of  50  millimeters, 
might  in  some  skulls  lead  one  to  make  the  whole  injection  directly 
into  the  nasal  fossa.  This  injection  of  the  second  division  is  more 
difficult  than  that  of  the  third.  If  for  some  reason  the  nerve  is  not 
located  by  the  directions  given,  the  needle  may  be  made  to  travel  still 
farther  forward  until  the  posterior  surface  of  the  superior  maxillary 
bone  is  encountered,  and  then  to  travel  upward  as  far  as  possible  where 
the  nerve  is  encountered,  lying  in  a  shallow  groove  on  the  upper  pos- 
terior part  of  the  maxillary  bone  (Fig.  430).  If,  in  doing  this,  the 
needle  is  inserted  too  deeply,  the  injection  may  be  made  into  the  orbit 
through  the  sphenomaxillary  fissure.  In  attempting  this  in  a  skull 
that  is  affected  with  osteoporosis,  the  injection  might  be  landed  in  the 
antrum  (Fig.  431).  With  Weiner's  fluid  this  would  be  of  small  con- 
sequence, but  alcohol  is  irritating.  We  have  had  this  accident  happen 
once. 

Injection    oe    the    Sphenopaeatine    Ganglion. — In    view    of 
Sluder's  work  on  neuralgia  associated  with  iiTitations  near  the  spheno- 


TIC  DOULOUREUX. 


661 


palatine  (Meckel's)  ganglion,  it  is  desirable  to  have  a  definite  technique 
for  reaching  this  ganglion.  Sluder  has  been  in  the  habit  of  injecting 
this  ganglion  through  the  nose  by  piercing  the  vertical  plate  of  the 
palate  bone,  but  with  an  operator  less  skilled,  this  would  be  a  very 
uncertain  mode  of  approach.  Dr.  Sluder  and  the  writer  have  made 
a  study  of  the  practicability  of  an  external  approach.  When  the 
needle  is  inserted,  as  advised  above  for  reaching  the  second  division, 
the  point  of  the  needle  usually  stops  in  front  of,  or  external  to,  the  gan- 
glion. It  may  be  inserted  just  below  the  malar  bone  at  a  point  di- 
rectly below  the  angle  between  the  temporal  border  of  the  malar  bone 
and  the  upper  border  of  the  zygoma.  The  needle  is  pushed  slightly 
upward  and  a  very  little  backward  until  the  pterygoid  process  is  en- 
countered. The  needle  is  then  slipped  forward  until  it  enters  the 
sphenomaxillary  fossa.     The  injection  is  made  while  moving  the  point 


Fig.  432.  Skull  with  osteoporosis.  C,  openings  into  the  anterior  fossa.  N,  opening 
into  the  nasal  fossa.  It  will  be  seen  that  along  the  line  of  the  frontosphenoidal  suture 
there  are  no  perforations,  nor  have  we  observed  them  in  any  skull  examined. 


of  the  needle  up  and  down  in  the  fossa,  at  a  depth  of  5  millimeters 
greater  than  that  at  which  the  point  was  when  it  encountered  the  ptery- 
goid process.  The  mouth  should  be  wide  open.  The  success  of  this 
injection  is  determined  by  the  anesthesia  developed  over  the  hard  palate 
and  within  the  nose  over  the  turbinate  bones  and  septum. 

In  many  skulls  a  more  direct  approach  could  be  made  by  entering 
the  needle  just  within  the  angle  between  the  temporal  border  of  the 
malar  bone  and  the  upper  border  of  the  zygoma,  and  passing  it  inward 
and  very  slightly  upward.  The  needle  would  encounter  the  external 
surface  of  the  greater  wing  of  the  sphenoid  bone,  and  then,  by  de- 
pressing the  point,  it  would  enter  the  sphenomaxillary  fossa.  The 
injection  is  to  be  made  at  a  depth  of  2  centimeters  greater  than  at  the 
outer  surface  of  the  great  wing  of  the  sphenoid.  In  skulls  of  some 
muscular  persons,  the  prominence  of  the  zygomatic  crest  might  render 
this  approach  impracticable. 


662 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


Injection  of  the  First  or  Ophthalmic  Division. — This  must  be 
injected  deep  in  the  orbit  just  as  it  emerges  from  the  sphenoidal  fis- 
sure. The  frontal  and  lacrymal  branches  enter  the  orbit  through  the 
outer  part  of  the  fissure,  but  the  nasal  branch  lies  rather  toward  its 
inner  extremity.  In  making  this  injection,  it  is  not  permissible  to 
insert  the  needle  beyond  the  outer  extremity  of  the  sphenoidal  fissure. 
The  injection  is  made  by  inserting  the  needle  under  the  external  angular 
process  of  the  frontal  bone  (Fig.  433),  and  following  the  outer  wall  of 
the  orbit  closely,  backward,  inward,  and  very  slightly  downward  to  a 
depth  of  30  to  35  millimeters,  depending  on  the  size  of  the  skull.  In 
a  number  of  skulls  the  distance  of  the  outer  end  of  the  sphenoidal 
fissures  from  the  external  angular  process  of  the  frontal  bone  varied 


Fig.  433.  Injection  of  the  first  frontal  and  lacrymal  branches  of  the  first  division. 
E,  point  of  entrance  of  the  neeedle.  S,  sphenoidal  fissure.  C,  perforation  into  the  an- 
terior cranial  fossa.     F,  foramina  leading  to  the  sphenoparietal  sinus. 


from  33  to  4o  millimeters.  In  some  skulls  the  needle  could  have  been 
pushed  10  millimeters  beyond  the  outer  end  of  the  fissure  without  en- 
tering the  anterior  cranial  fossa,  while  in  others  it  would  have  entered 
immediately.  In  none  of  the  skulls  examined  would  the  needle  have 
touched  the  optic  nerve  at  a  depth  of  less  than  43  millimeters.  The 
fluid  easily  disseminates  in  the  loose  tissue  in  the  back  of  the  orbit, 
and  in  most  instances  a  number  of  nerves  are  affected  by  the  injection. 
We  have  seen  dimness  of  vision  follow,  which  passed  off  in  ten  days 
or  two  weeks,  while  the  diplopia  due  to  partial  paralysis  of  the  ocular 
muscles  has  lasted  three  weeks  or  more.  In  one  case,  a  very  sharp  or- 
bital hemorrhage,  that  caused  closure  of  the  lids  and  a  pronounced 
exophthalmos  that  appeared  in  two  minutes,  caused  no  visual  or  other 


TIC  DOULOUREUX. 


663 


subjective  symptom  and  was  apparently  disseminated  by  the  next  day. 
That  there  is  much  greater  danger  in  making  this  injection  than  in 
either  of  the  other  two,  there  can  be  no  doubt.  Patrick  states  that 
he  has  abandoned  it  on  account  of  the  extra  hazard.  The  experience 
quoted  above  tends  to  show  that  this  danger  is  not  due  to  the  possibility 
of  hemorrhages.  To  what  the  bHndness  was  due,  in  the  case  elsewhere 
cited,  we  do  not  know ;  possibly  an  excessive  inflammatory  reaction 
of  the  optic  nerve  due  to  the  irritating  fluid,  for  the  nerve  itself  would 
probably  not  be  touched. 

In  many  skulls  of  older  persons  there  are  perforations  in  the  orbital 
plate  of  the  frontal  bone,  which  forms  the  roof  of  the  orbit  (Fig.  432)  ; 


Fig.    43-i. 


Fig.    435. 


Fig.  434  shows  the  anesthesia  that  resulted  from  a  deep  injection  of  the  second 
division  of  the  fifth  nerve  in  the  case  shown  in  Fig.  423.  The  palate  is  shown  and  also 
the  right  half  of  the  upper  gum. 

Fig.  435  shows  the  relative  amount  of  anesthesia  that  existed  one  month  after  the 
injection.  Six  months  after  the  injection,  the  anesthesia  had  entirely  disappeared. 
Some  paresthesia  still  persisted  ten  months  after  the  injection.  Pain  returned  two 
years  later. 

but  if  the  direction  given,  to  keep  the  point  of  the  needle  applied  to  the 
outer  wall  of  the  orbit,  is  observed,  there  will  be  no  danger  of  entering 
one  of  these.  In  some  skulls  (Fig.  433)  there  is  a  foramen  in  the  suture 
between  the  orbital  plate  of  the  frontal  bone  and  the  lesser  wing  of 
the  sphenoid  that  transmits  a  vein  from  the  orbit  to  the  sphenoparietal 
sinus.  This  lies  directly  in  the  path  of  the  needle  and  may  be  of  large 
size.  It  is  not  inconceivable  that  the  point,  becoming  engaged  in  such 
a  foramen,  might  cause  a  part  of  the  injection  to  be  shot  into  the  sinus. 
With  Weiner's  solution  this  would  have  no  serious  consequence,  but 
the  injection  of  alcohol  might  result  in  embolism.     On  the  whole,  avul- 


664 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


sion  of  the  frontal  nerve  is  a  safer  operation  than  the  injection  of  any 
corrosive  or  hardening  fluid  deep  into  the  orbit.  At  least,  after  proper 
explanation,  the  choice  should  be  left  with  the  patient. 

The  immediate  effect  of  a  successful  injection  w^ith  the  alcohol 
formula  (page  651)  is  a  very  severe  pain  radiating  over  the  distribution 
of  the  nerve,  which  is  usually  quickly  followed  by  an  anesthesia  and  a 
subjective  numbness,  or  possibly  only  the  latter,  but  in  either  case  the 
neuralgic  pain  is  at  once  completely  relieved  (Figs.  434,  436,  and  438). 
There  will  be  paresthesia,  in  the  form  of  crawling  sensations  over  the 


Pig.    436. 


Fig.    437. 


Fig.  436  shows  the  anesthesia  that  resulted  from  the  injection  of  the  first  and 
second  division  of  the  left  fifth  on  April  26,  1909.  The  chart  was  made  on  April  27. 
It  will  be  seen  that  a  much  more  complete  anesthesia  was  obtained  over  the  first  than 
the  second  division.  Note  that  partial  anesthesia  extended  into  the  area  of  the  nasal 
branch  of  the  first  division.  There  was  some  diplopia  and  dimness  of  vision  after  the 
operation,  but  it  cleared  up  in  a  week. 

Fig.  437  shows  the  condition  of  anesthesia  on  May  1,  1909,  four  days  after  the 
injection.  In  October,  190S,  the  whole  of  the  frontal  nerve  had  been  removed  back  to 
the  sphenoidal  fissure,  which  probably  accounts  for  the  streak  of  absolute  anesthesia  that 
has  persisted.  The  other  anesthesia  spots  are  probably  due  to  some  damage  to  the 
nerve  fibers  during  the  injection.  Spots  A  and  B  were  tender,  due  probably  to  the  be- 
ginning of  the  return  of  protopathic  sensibility.  The  pain  in  this  case  returned  In  one 
month,  but  not  so  severely  as  before  operation.  The  anesthesia  had  not  entirely  disap- 
peared six  months  after  the  injection.  Ganglion  operation  refused.  The  obtaining  of 
the  definitely  limited  anesthesia  by  Injecting  the  orbit  after  the  avulsion  of  the  frontal 
nerve  brings  up  some  interesting  questions. 

distribution  of  the  affected  nerve,  and  a  sensation  of  stiffness  over  that 
side  of  the  face.  Complete  and  rather  persistent  loss  of  taste  and  also  a 
weakness  of  the  muscle  of  mastication  on  that  side  often  follow  the 
injection  of  the  third  division.  With  the  alcoholic  injections  of  the 
first  and  sometimes  of  the  second  divisions,  there  is  a  great  swelling 
of  the  lids  which  subsides  in  forty-eight  hours,  and  in  all  cases  a  slight 
swelling  of  the  face  that  may  last  several  days.  There  is  often  a  little 
fever  that  may  at  first  go  to  102°  or  103°,  but  we  have  never  seen  any 
serious  inflammatory  condition  result.  In  a  few  days  most  of  the 
anesthesia  will  have  disappeared  (Figs.  434  to  439),  but  traces  of  it  will 
remain  for  six  months  to  a  year.     The  paresthesia  may  last  longer. 


TIC  DOULOUREUX.  665 

In  75  per  cent  of  the  cases  the  pain  had  not  returned,  when  last  heard 
from  at  periods  varying  from  several  months  to  five  years,  and  all  had 
experienced  some  benefit  from  the  operation.  If  the  operation  proves 
unsuccessful,  the  injection  may  be  repeated  as  soon  as  the  reaction 
subsides.  The  patient  can  be  assured  that  the  second  injection  will  not 
be  as  painful  as  the  first,  at  least  not  until  the  nerve  is  actually  struck ; 
and  then  the  pain  may  be  over  in  a  few  minutes.  Sometimes  it  is  more 
persistent.  A  number  of  patients  have  returned  for  reinjection  at 
periods  mostly  between  fifteen  months  and  two  and  one  half  years. 
So  far,  these  have  experienced  relief  from  the  second  injection,  but  it 


Fig.    438.  Fig.    439. 

Fig.  438  shows  the  anesthesia  after  injection  for  neuralgia  of  the  second  and  third 
division.  The  second  division  was  Injected  on  March  2,  1909,  with  almost  total  anes- 
thesia resulting.  The  third  division  was  Injected  March  24,  1909.  It  was  charted  on 
March  25,  1909.  It  will  be  seen  that  the  anesthesia  to  pain  and  touch  over  the  second 
division  has  considerably  lessened  between  the  time  of  injection  and  the  time  of  chart- 
ing. At  the  time  of  charting  it  was  found  that  on  the  right  side,  the  lingual  and  labial 
surfaces  of  the  lower  gum,  the  superior,  inferior,  and  lateral  surfaces  of  the  anterior 
two  thirds  of  the  tongue,  and  the  internal  surface  of  the  cheek  below  the  occlusal  line 
were  completely  anesthetic  to  touch,  pain,  and  temperature ;  and  sense  of  taste  was  lost 
in  the  anterior  two  thirds  of  the  right  half  of  the  tongue. 

Fig.  439  shows  the  area  on  the  surface  that  was  completely  anesthetic  to  heat  and 
cold.  The  anesthesia  had  not  entirely  disappeared  nine  months  after  the  injection. 
Pain  had  persisted  for  fifteen  years  before  injection,  and  had  not  returned  one  year 
after  injection. 

is  possible  that  a  time  may  come  in  many  cases  when  the  injection 
will  no  longer  be  efficient  and  that  a  ganglion  operation  may  eventually 
be  necessary. 

It  is  always  well  to  start  with  the  understanding  that  it  may  require 
more  than  one  injection  to  cure  the  pain.  When  the  two  divisions  are 
involved,  they  may  be  injected  at  the  same  sitting  if  the  patient  stands 
it  well ;  but  the  most  painful  branch  should  be  treated  first.  Sometimes 
the  injection  of  one  division  will  be  followed  by  relief  of  a  pain  spot 
that  was  situated  over  the  distribution  of  another  division,  but  often  the 
neuralgia  in  the  least  affected  nerve  will  become  apparently  worse  after 


666  SURGERY  OF  THE  MOUTH  AND  JAWS. 

its  more  severely  affected  neighbor  has  been  relieved.  The  second 
and  third  can  often  be  injected  with  one  insertion  of  the  needle,  enter- 
ing it  as  for  the  injection  of  the  third  division,  and  when  that  injection 
is  made,  shifting  it  forward  to  the  second. 

Nerve  Resection. — Avulsion  o^  the  Frontal  Nerve. — While  ap- 
parently a  simpler  operation,  resection  of  the  supraorbital  nerve  is 
hardly  a  justifiable  operation  on  account  of  the  slight  likelihood  of  its 
being  of  any  great  benefit.  Normally  there  is  a  branch  of  the  nerve 
that  leaves  the  orbit  to  the  inner  side  of  the  notch ;  both  this  and  the 
supratrochlear,  which  is  also  likely  to  be  involved,  are  difficult  to  find 
in  the  orbicularis  palpebrarum  muscle. 

To  avulse  the  trunk  of  the  frontal  nerve,  the  eyebrow  is  cleaned, 
but  not  necessarily  shaved.  The  eyelid  is  held  down  with  a  sponge, 
and  an  incision  made  that  starts  near  the  outer  end,  follows  the  eye- 
brow, and  curves  downward  at  the  root  of  the  nose.  The  incision  is 
made  down  to  the  periosteum,  and  all  superficial  tissues  are  turned 
downward,  the  supraorbital  nerve  being  identified  in  the  notch  before 
the  relations  are  greatly  disturbed.  The  orbital  contents  are  gently 
depressed  with  a  spatula,  and  the  supraorbital  nerve  is  followed  back- 
ward into  the  orbit  until  the  supratrochlear  branch  is  found  passing  to 
the  trochlea  of  the  superior  oblique  tendon.  As  far  back  as  can  be 
seen,  the  whole  nerve  trunk  is  grasped  with  a  pointed  artery  forceps 
and  twisted  out.  The  skin  and  muscles  are  sutured  en  masse  with 
deeper  interrupted  sutures  without  drainage. 

Avulsion  oe  the  Nasal  Nerve. — The  nasal  nerve  is  exposed  by 
an  incision  extending  from  the  supraorbital  notch  along  the  inner 
border  of  the  orbit.  The  tissues,  including  the  lacrymal  sac,  are 
drawn  outward,  the  bone  being  followed  closely  to  a  depth  of  from  2 
to  2^  centimeters.  The  tendon  of  the  superior  oblique  muscle,  which 
is  attached  to  the  bone  internal  to  and  behind  the  supraorbital  notch,  is 
to  be  avoided.  The  nerve  leaves  the  orbit  through  the  anterior  eth- 
moidal foramen,  where  it  can  be  caught  with  a  hook  and  avulsed.  If 
possible,  the  anterior  ethmoidal  artery  that  accompanies  it  should  not 
Ijc  cut.  If  bleeding  from  the  little  artery  should  l)e  persistent,  a  strip 
of  gauze  may  be  left  in  contact  with  the  bleeding  point  and  protruding 
through  the  wound.  In  closing  the  wound,  use  interrupted  sutures 
and  avoid  puncturing  the  lacrymal  sac  with  the  needle. 

Intracranial  Operations. — If  the  attack  upon  the  peripheral 
nerves  proves  primarily  or  ultimately  a  failure,  then,  to  obtain  relief,  the 
interruption  in  the  sensory  conduction  tract  must  be  made  at  or  proxi- 
mal to  the  Gasserian  ganglion. 

In  1884,  W.  J.  E.  Mears  first  proposed  the  removal  of  the  ganglion 
for  tic  douloureux,  and  in  1890,  Rose  performed  the  first  successful 


TIC  DOULOUREUX. 


667 


operation.  In  1891,  Horsley,  failing  to  remove  the  ganglion,  avulsed 
the  sensory  root.  The  complete  extirpation  of  the  ganglion  is  an  ex- 
tremely difficult  operation,  and  one  attended  by  very  profuse  and  un- 
avoidable hemorrhage. 

The  difficulty  and  danger  encountered  in  separating  the  ophthalmic 
division  from  the  wall  of  the  cavernous  sinus  are  such  that  Hutchinson 
has  been  led  to  abandon  this  part  of  the  ganglion  and  to  content  him- 
self with  the  removal  of  the  parts  related  to  the  second  and  third  di- 
vision. In  many  cases,  however,  the  first  division  is  affected  or  be- 
comes so  later,  and  in  a  number  of  failures  after  supposed  complete 
removal,  it  is  in  the  distribution  of  the  ophthalmic  that  the  pain  has 
returned. 


Fig.    440.      Head    apron    on    standard, 
ing.     The  Inner  part  is  rubber  dam. 


Outer   part    is    of   double-faced    rubber   sheet- 


The  section  or  avulsion  of  the  posterior  root  of  the  ganglion  is  a 
simpler  operation,  and  is  freer  from  hemorrhage.  It  is  productive  of 
less  shock,  and  in  doing  it,  one  may  be  certain  that  all  connection  with 
the  higher  perceptive  centers  has  been  destroyed.  It  is  probable  that 
the  ganglion  has  some  trophic  functions  that  are  not  interfered  with  by 
the  posterior  root  section ;  therefore  the  operation  of  extirpation  of  the 
ganglion  is  being  replaced  by  some  operators  for  that  of  the  posterior 
root  section.  Spiller  first  urged  this  as  the  operation  of  election,  and 
Frazier  has  performed  it  probably  more  often  than  any  one  else.  The 
only  objection  that  can  be  urged  against  the  latter  operation  in  favor 
of  the  former  is  that  in  a  certain  percentage  of  cases  the  skillful  oper- 
ator can  preserve  the  motor  root  intact  while  extirpating  the  ganglion, 


668 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


which  is  almost  impossible  to  do  while  simply  cutting  the  posterior 
root. 

Operation  of  Cutting  the  Posterior  Root  oe  the  Gasserian 
Ganglion. — The  danger  of  accidental  meningeal  infection  is  lessened 
by  following  the  suggestion  of  Crow  and  Gushing,  which  is  to  admin- 
ister hexamethylene  tetramin  in  large  doses  before  and  after  any  oper- 
ation in  which  the  dura  is  opened.  One-half  gram  of  urotropin  each 
six  hours  will  liberate  a  demonstrable  quantity  of  formaldehyde  in  the 


Fig.    -}41.      Mead    apron    in    position.      This   completely   separates   the   operative   field 
from  the  anesthetic  by  an  impervious  wall. 


cerebrospinal  fluid.  We  usually  give  four  grams  a  day  in  all  intra- 
cranial operations. 

The  whole  head,  or  at  least  the  affected  side,  is  shaved.  In  women 
the  shaving  of  the  whole  head  is  often  seriously  objected  to,  and  with 
care  a  clean  field  can  be  obtained  as  follows : 

Shave  on  the  affected  side  for  a  distance  of  3  centimeters  beyond 
the  line  of  the  proposed  incision.  Wash  the  scalp  and  hair  thoroughly 
and  rub  the  hair  dry.     Some  women  are  apt  to  take  cold  after  a  hair- 


TIC  DOULOUREUX.  669 

washing.  Plait  the  hair  on  the  opposite  pole  of  the  head,  so  as  to 
draw  it  away  from  the  shaved  field.  To  avoid  the  risk  of  contami- 
nating the  field  while  seeking  for  landmarks,  after  the  area  is  cleaned, 
before  the  protective  towels  are  in  place,  the  line  of  incision  is  outlined 
with  the  point  of  a  knife  after  the  skin  is  prepared.  The  skin  is  dis- 
infected, and  if  the  whole  scalp  has  not  been  shaved,  the  hair  margin 
next  to  the  field  is  plastered  down  with  sterile  adhesive  plaster,  which 
will  prevent  the  hair  from  straying  over  into  the  field.  This  adhesive 
plaster  is  removed  with  gasolin  after  the  wound  has  healed. 

The  operation  is  ordinarily  done  under  morphin.  atropin,  gas,  or 
ether  anesthesia,  but  has  been  performed  with  a  local  anesthetic. 

Before  starting  the  operation,  it  has  been  our  custom  to  withdraw 
30    cubic  centimeters    of   spinal    fluid   by   lum.bar    puncture.     By   this 


Pig.    442.      Line    of    incision    for    resection    of    the    posterior    root    of    the    Gasserian 
ganglion. 

means  more  room  is  gained  in  the  subdural  space,  and  there  is  less 
compression  of  the  intracranial  contents.  The  patient  sits  almost  erect 
in  an  operating  chair  or  on  a  table  with  a  back-rest  that  supports  the 
head.  The  sterilized  head  apron  (Fig.  4J:0)  or  sheet  is  adjusted. 
The  immediate  operation  field  is  surrounded  by  towels,  that  are  pinned 
to  the  scalp  or  fastened  with  small  tenaculum  forceps  (Fig.  441).  A 
horseshoe  incision  is  made,  beginning  at  the  middle  of  the  zygoma  and 
carried  at  first  upward  and  slightly  forward,  the  highest  point  being 
4  centimeters  above  the  zygoma  or  on  the  level  of  the  external  angular 
process  of  the  frontal  bone.  It  terminates  just  below  and  behind  the 
upper  part  of  the  attachment  of  the  ear.  The  incision  (Fig.  442 )  is 
made  straight  down  to  the  bone,  and  the  flap,  which  includes  the  peri- 
osteum, is  turned  down.  The  scalp  flap  is  4  by  4^  centimeters,  and 
should  not  extend  anteriorly  beyond  the  average  hair-line.     The  in- 


670 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


cision  is  somewhat  larger  than  that  used  by  Frazier.  In  doing  this, 
the  branches  of  the  temporal  artery  and  vein  are  cut  and  must  be 
caught.  When  the  bleeding  of  the  fiap  and  scalp  is  controlled,  the 
flap  is  held  down  by  a  tenaculum  forceps  (Fig.  443),  and  is  covered  by 
a  towel  which  is  pinned  in  place.  The  squamous  part  of  the  temporal 
bone  is  opened  in  the  middle  of  the  bare  area  and  rongeured  away 
until  an  opening  3  by  4  centimeters  is  made,  that  extends  as  far  for- 
ward as  the  vertical  part  of  the  middle  meningeal  artery  and  as  far 


Fig.   443.      Section   of  the   posterior  root  of  the  fifth    nerve. 
opened,  and  dura  exposed. 


Flap   turned   down,   skull 


below  the  upper  border  of  the  zygoma  as  can  be  conveniently  done. 
The  squamous  part  is  of  compact  bone,  and  does  not  usually  bleed 
from  diploe. 

In  this  operation  the  nerve  root  is  reached  by  raising  the  dura, 
with  the  enclosed  brain,  lyi  centimeters  from  the  cranial  floor;  this 
must  cause  some  compression,  and  for  this  reason  we  resort  to  pre- 
liminary spinal  puncture.  In  Krause's  operation  for  the  extirpation 
of  the  ganglion,  the  contusion  that  occurs  while  elevating  the  brain  has 
been   the  cause   of   fatal   brain   injury.     Krause   suggests   making   a 


TIC  DOULOUREUX. 


671 


minute  incision  in  the  dura  to  allow  the  escape  of  the  cerebrospinal 
fluid.  This  or  a  spinal  puncture  will  lessen  the  danger  of  brain  injury, 
if  the  end  of  the  retractor  is  not  pressed  sharply  against  the  cerebrum. 
If  this  opening  is  made,  it  should  not  be  larger  than  2  millimeters,  as 
the  brain  substance  might  protrude  through  a  larger  one.  A  possible 
objection  to  this  puncture  is  that  in  case  of  infection  it  might  more 
easily  permit  of  intradural  extension.  The  dura  and  the  brain  are 
elevated  by  inserting  a  spatula  or  elevator  along  the  cranial  floor. 
There  will  be  found  some  attachment  of  the  dura  along  the  petro- 
squamosal  suture  (Fig.  444),  into  which  small  branches  of  the  menin- 
geal artery  may  enter.     Hemorrhage  from  these  is  controlled  by  apply- 


Second  division 
First  division 

Third  division 

Cavernous  sinus 

Posterior  root 


Middle  meningeal 
artery. 


Petrosquamosal 
suture. 


Cut  edge  of  dura,  passing 
under  ganglion 


...Elevation  over  superior  semicircular 
canal. 
Great  superficial  petrosal  nerve. 


Fig.    4-14.      Area   on   the   floor   of   the    middle   cranial   fossa,    from   which  the   dura    is 
elevated   (as  indicated  by  the  dotted  line),  and  the  structures  exposed. 

ing  a  small  fiat  gauze  sponge  and  holding  in  place  with  a  retractor. 
The  retractor  should  be  of  thin  metal  that  can,  if  desired,  be  rebent 
during  the  operation.  The  blade  should  be  ly^  to  3  centimeters  wide 
and  4  centimeters  long.  Frazier  uses  the  handle  of  a  spoon  bent  to 
the  desired  shape.  At  a  depth  of  about  2  centimeters  the  trunk  of  the 
middle  meningeal  artery  will  be  seen  emerging  from  the  foramen  spi- 
nosum.  The  artery  has  a  free  course  of  about  5  millimeters  before  it 
enters  the  dura  (Fig.  445).  This  part  of  the  trunk  is  to  be  carefully 
freed  all  around.  It  is  at  once  surrounded  by  a  ligature  or  grasped 
close  to  the   dura  with  small   pointed   artery   forceps.     In   the   latter 


672 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


case  the  artery  is  cut  between  the  dura  and  the  forceps,  and  a  linen 
or  silk  ligature  is  thrown  around  the  trunk  and  tied  before  the  forceps 

are  released  (Fig.  446).  This  method  of  ligating  the  artery  precludes 
the  possibility  of  cutting  the  ligature  with  the  artery,  or  cutting  the 
artery  too  close  to  the  ligature.  Immediately  beyond  the  artery  lies 
the  Gasserian  ganglion  inclosed  in  an  envelope  formed  by  the  splitting 
of  the  dura  into  two  layers.  At  the  outer  edge  of  the  ganglion  the  pro- 
cess of  the  dura  that  passes  under  the  ganglion  is  incised  with  a  knife 
or  sharp  elevator.  This  exposes  the  outer  border  of  the  ganglion,  and 
dissection  is  continued  until  the  posterior  root  is  found  entering  its 
posterior  part  and  until  the  outer  wall  of  the  cavernous  sinus  is  en- 
countered  (Fig.  447).     The  posterior  root  is  not  anywhere  adherent 


Fig.   445.      Free   part  of  middle  meningeal   artery,  passing  from   the   foramen   splno- 
sum  to  the  dura. 


to  its  dural  coverings,  and  it  can  be  lifted  from  its  bed  with  ease.  It 
is  not  a  solid  nerve  trunk,  but  is  composed  of  a  number  of  detached 
threads ;  all  of  which  must  be  cut  in  order  to  ensure  the  success  of  the 
operation.  This  is  best  done  by  passing  a  small  blunt  hook  across  to 
the  wall  of  the  cavernous  sinus  and  drawing  the  root  outward  until  it 
can  be  caught  with  forceps  and  avulsed.  The  hook  used  for  this 
purpose  should  not  only  be  blunt  but  smoothly  rounded,  and  even 
probe-pointed,  so  that  there  can  be  no  danger  of  injury  to  the  wall  of 
the  sinus.  It  is  not  practical  to  attempt  to  recognize  and  preserve  the 
motor  root. 

The  operative  field  traversed  along  the  base  of  the  skull,  the  vari- 
ous   structures   encountered,   and    the    relative    size   of   the   posterior 


TIC  DOULOUREUX. 


673 


root  are  shown  in  Fig.  444.  The  operator  must  not  work  too  far  back- 
ward before  opening  the  envelope  of  the  gangHon,  lest  the  superior 
petrosal  sinus,  which  lies  just  behind  the  elevation  of  the  superior 
semicircular  canal,  be  endangered,  bleeding  from  which  would  be  em- 
barrassing. As  the  operation  progresses,  hemorrhage  is  controlled  by 
the  pressure  of  folded  strips  of  gauze  held  in  place  by  the  retractor  or 
narrow  spatula.  Frazier  recommends  that,  after  the  posterior  root  is 
cut,  the  patient  should  be  allowed  to  come  from  under  the  anesthetic 
in  order  that  the  cutaneous  sensations  can  be  tested  to  be  sure  the  whole 


Pig.    446.      Tying  the  middle   meuingeal   artery. 


trunk  is  severed.  A  rubber  tissue  drain  is  inserted,  and  the  wound 
is  closed  by  suturing  the  flap  in  place  with  interrupted  silkworm  gut 
sutures,  that  embrace  the  full  thickness  of  the  scalp.  The  drain  is  re- 
moved in  twenty-four  hours.  The  sutures  which  have  not  drawn  tight 
are  cut  in  twenty- four  hours  and  are  removed  in  two  days.  If  the 
motor  root  were  preserved,  the  temporal  muscle  would  have  to  be 
sutured  separately. 

The  mortality  from  the  more  recent  ganglion  operations  in  the 
hands  of  experienced  operators  is  less  than  4  per  cent.  Frazier  had 
one  death  ten  days  after  operation,  out  of  28  operations  of  posterior 


674 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


root  section.  In  ganglion  extirpation  most  of  the  deaths  have  occurred 
within  the  first  twenty-four  hours  after  the  operation  from  shock  or 
hemorrhage,  both  of  which  are  less  in  the  root  operation  than  in  the 
extirpation. 

The  efifects  of  the  operation  are  paralysis  of  the  muscles  of  mastica- 
tion in  the  afifected  side  when  the  motor  root  is  cut,  and  an  absolute 
anesthesia  over  the  areas  that  are  supplied  wholly  by  the  fifth  nerve. 
There  should  be  no  risk  of  injury  to  the  third,  fourth,  and  sixth  nerves 


^M.M,f\RTERY 
GRNQLION 
I    [CUT  EDGE  OF 
I      DURRLSHERTH 
^POSTERIOR  ROOT 


Fig.    44" 


Display   of   the  posterior  pari 


the   ganglion    and    of    the   posterior    root. 


in  this  operation,  and  if  the  brain  is  elevated  evenly  and  carefully,  no 
cerebral  damage  will  result. 

Ulceration  of  the  cornea  is  a  common  postoperative  complication 
of  the  removal  of  the  ganglion,  but  according  to  Spiller,  it  is  not  so 
frequent  after  posterior  root  section.  The  eye  should  be  protected  by 
a  transparent  shield  for  several  weeks  after  the  operation,  and  the  pos- 
sibility of  corneal  ulceration  should  not  be  dismissed  till  after  three 
months  have  elapsed.  It  is  very  probable,  but  not  absolutely  certain, 
that  posterior  root  section  will  cure  every  case  of  tic  douloureux. 


CHAPTER  XLV. 
LOCAL  ANESTHESIA.^ 

When,  in  1853,  Alexander  Wood  popularized  a  method  of  general 
medication  by  means  of  hypodermic  injections,  he  gave  the  impetus 
toward  a  method  which  is  now  used  universally — namely,  to  inject 
some  drug  for  producing  local  anesthesia.  At  that  time,  however, 
morphin  or  tincture  of  opium  was  the  drug  used,  and  it  was  not  until 
cocain  was  tried  that  the  full  value  of  the  hypodermic  injection  was 
realized. 

Cocain  was  discovered  by  Niemann  in  1859,  but  it  required  twenty- 
five  years  to  make  known  the  remarkable  anesthetic  properties  which 
this  alkaloid  possessed  when  applied  in  the  readily  soluble  form  of  its 
hydrochloric  salt.  It  was  on  September  15,  1884,  that  Carl  Koller,  of 
Vienna,  presented  his  epoch-making  communication  at  the  Ophthalmo- 
logic Congress  at  Heidelberg,  in  which  he  demonstrated  the  effects  of 
cocain  as  a  local  anesthetic.  With  the  introduction  of  this  drug  into 
therapeutics,  local  anesthesia  achieved  results  which  were  beyond  ex- 
pectation, and  its  final  adoption  created  a  new  area  in  local  anesthesia. 

MEANS   OF   PRODUCING   LOCAL   ANESTHESIA. 

We  produce  local  anesthesia  by  inhibiting  the  sensory  nerve  fibers 
in  their  course  or  at  their  peripheral  end-organs.  This  is  done:  (a)  by 
inhibiting  the  function  of  the  peripheral  nerves  in  a  small  area  of 
tissue — terminal  anesthesia;  or  (b)  by  blocking  the  conductivity  of  a 
sensory  nerve  trunk  somewhere  between  the  brain  and  the  periphery — 
conduction  anesthesia.  There  are  two  methods  of  producing  local 
anesthesia:  (1)  the  production  of  local  anemia;  (2)  the  action  of  cer- 
tain drugs  that  directly  obtund  the  conducting  power  of  sensory  nerves. 

Means  of  Producing  Anemia. — Local  anemia  can  be  produced 
(1)  by  the  Esmarch  elastic  bandage.  In  surgery  of  the  head,  how- 
ever, this  obviously  cannot  be  used.  (2)  A  second  means  of  pro- 
ducing anemia  is  by  reducing  the  temperature  of  the  body  by  the  appli- 
cation of  cold.  This  is  best  accomplished  by  the  use  of  pure  ethyl 
chlorid  (boiling  point  55°  F.,  13°  C.)  or  an  ether  spray.  Mixtures  of 
ethyl   chlorid   and   methyl   chlorid   in   various    proportions — known   as 


iThe  history  of  local  anesthesia  and  its  applications  to  dental  operations  are 
largely  gathered  from  the  article  by  Dr.  Hermann  Prinz,  "Modern  Methods  of  Pro- 
ducing Local  Anesthesia,"  in  the  Dental  Summary,  February,  March,  and  April, 
1912. 

675 


676  SURGERY  OF  THE  MOUTH  AND  JAWS. 

anestol,  anestile,  coryl,  methethyl,  etc. — are  extensively  used  in  oral 
and  general  surgery.  These  mixtures  produce  a  deeper  anesthesia,  but 
they  may  cut  off  the  circulation  so  completely  as  to  produce  necrosis. 
Carbonic  acid  snow,  liquid  air,  and  liquid  nitrous  oxid  gas  all  have  a 
boiling  point  far  below  zero  and  have  been  recommended,  but  they  are 
not  so  easy  to  administer  and  are  dangerous. 

Ethyl  chlorid  is  the  most  satisfactory  agent  for  producing  refriger- 
ation of  the  tissues.  For  the  extraction  of  teeth  and  any  minor  oper- 
ation about  the  head  and  oral  cavity,  the  capillary  end  of  the  tube 
should  be  held  about  six  to  ten  inches  from  the  part  to  be  sprayed. 
The  Gebauer  tube  is  fitted  with  a  spray  nozzle,  which  shortens  the 
distance  to  one  or  two  inches,  and  is  especially  well  adapted  for  dental 
purposes.  The  part  should  be  sprayed  until  the  tissues  are  covered 
with  ice  crystals  and  have  turned  white.  The  tissues  to  be  anes- 
thetized should  be  dried  well,  and  the  adjacent  tissues  should  be  rubbed 
with  vaselin  or  glycerin.  If  the  stream  is  to  be  directed  to  some  part 
within  the  mouth,  cotton  rolls  and  gauze  should  be  packed  around,  to 
prevent  the  liquid  from  running  down  the  throat.  For  the  extraction 
of  teeth  the  liquid  should  be  projected  directly  upon  the  surface  of 
the  gum,  as  near  the  apex  of  the  root  as  possible,  but  care  should  be 
taken  to  protect  the  crown  of  the  tooth  on  account  of  the  painful  action 
of  the  cold  on  this  part.  On  account  of  the  difficulty  of  directing  the 
stream  of  ethyl  chlorid  upon  the  tissues  in  the  posterior  part  of  the 
mouth,  it  is  not  sucessfully  applied  in  these  regions.  The  intense 
pain  produced  by  the  extreme  cold  prohibits  its  use  in  pulpitis  and 
acute  pericementitis.  To  anesthetize  the  second  and  third  branch  of 
the  fifth  nerve,  it  is  recommended  to  direct  the  stream  of  ethyl  chlorid 
upon  the  cheek  in  front  of  the  tragus  of  the  ear,  but  we  have  not  seen 
good  results  from  such  a  procedure. 

The  injection  of  adrenalin  is  a  third  means  of  producing  local 
anemia.  It  acts  as  a  powerful  vasoconstrictor  and  stimulates  the 
smooth  muscular  coat  of  the  blood  vessels.  While  adrenalin  does  not 
possess  local  anesthetic  action,  it  increases  very  markedly  the  effect  of 
certain  anesthetics  when  combined  with  them.  A  very  weak  solution 
gives  the  desired  local  result  and  has  no  effect  upon  the  tissues  or  on 
the  healing  of  the  wound. 

A  synthetic  suprarenin  has  recently  been  introduced  which,  with 
hydrochloric  acid,  forms  a  stable  and  readily  soluble  salt.  Its  advan- 
tages over  the  organo-preparations  has  led  us  to  adopt  it  as  a  com- 
ponent in  the  preparation  of  local  anesthetic  solutions.  For  dental 
purposes — that  is,  for  injecting  into  the  gum  tissue — the  dose  may  be 
limited  to  one  drop  of  the  adrenalin  solution  (1 :1000),  or  the  synthetic 
suprarenin  solution   (1:1000),  added  to  each  cubic  centimeter  of  the 


LOCAL  ANESTHESIA.  677 

anesthetic  solution.  The  injection  of  plain  normal  saline  solution  into 
the  tissues,  under  pressure,  especially  into  the  skin,  will  obtund  the 
terminal  nerves.  This  method  is  frequently  used,  but  is  less  efficient 
and  has  no  advantage  over  a  very  weak  cocain  or  novocain  solution. 

Cocain  and  Substitute  Drugs. — Ever  since  the  introduction  of 
"cocain  into  materia  medica  for  the  purpose  of  producing  local  anes- 
thesia, quite  a  number  of  substitutes  have  been  placed  before  the  pro- 
fession, for  which  superiority  in  one  "respect  or  another  is  claimed  over 
the  original  cocain.  The  more  prominent  members  of  this  group  are 
tropacocain,  the  eucains,  acoin,  nirvanin,  alypin,  stovain,  novocain,  and 
very  recently,  quinin  and  urea  hydrochlorid.  None  of  these  com- 
pounds, with  the  exception  of  novocain,  has  proved  satisfactory  for  the 
purpose  in  view.  The  classical  researches  of  Braun  have  established 
certain  facts  which  are  imperative  to  the  value  of  a  local  anesthetic. 
These  facts  concern  their  relationship  to  the  tissues,  in  regard  to  their 
toxicity,  irritation,  solubility,  and  penetration,  and  to  the  toleration  of 
adrenalin. 

Although  the  novocain  has  the  same  anesthetizing  power  as  cocain 
when  injected  into  the  tissues,  it  is  not  so  easily  absorbed  on  a  mucous 
surface,  and  therefore,  for  anesthetizing  by  local  application,  cocain  is 
preferable  to  novocain.  Not  the  least  of  its  good  points  is  that  it  will 
combine  with  adrenalin  in  any  proportion,  without  lessening  the  effect 
of  the  latter.  When  adrenalin  is  added  to  the  novocain  solution,  it 
prolongs  its  action,  lessens  the  danger  of  general  intoxication,  and  en- 
ables the  operator  to  use  a  much  smaller  dose  that  he  could  employ  when 
he  uses  either  one  separately.  At  the  same  time,  however,  it  increases 
the  length  of  time  required  for  the  drug  to  act.  Sometimes  fifteen 
minutes  must  elapse  before  anesthesia  is  accomplished,  when  adrenalin 
has  been  added  to  the  solution. 

The  dose  of  novocain  is  about  one  third  of  a  grain  in  a  1^  or  2 
per  cent  solution.  A  Vs  to  Y^  per  cent  solution  of  novocain  combined 
with  adrenalin  chlorid  in  physiological  salt  solution  has  been  frequently 
injected  by  us  in  quantities  of  2  grains  of  the  drug  for  a  single  anes- 
thesia. The  addition  of  the  adrenalin,  with  its  powerful  vasocon- 
strictor action,  confines  the  injected  novocain  to  a  given  area.  It  is  the 
important  factor  which  prevents  the  ready  absorption  of  both  drugs, 
and  consequently  largely  nullifies  poisonous  results. 

Absorption  ot  Poisonous  Drugs. — There  are  some  persons, 
usually  those  who  might  be  described  as  "nervous,"  upon  whom  it  is 
very  difficult  to  establish  a  satisfactory  local  anesthesia ;  and  it  is  diffi- 
cult to  state  when  a  patient  may  collapse  under  a  local  anesthetic.  It 
is  merely  a  matter  of  using  common  sense  to  decide  whether  a  patient 
shall  receive  a  local  anesthetic  or  not.     If,  for  instance,  a  patient  ap- 


678  SURGERY  OF  THE  MOUTH  AND  JAWS. 

pears  to  be  in  a  condition  that  indicates  general  derangement  of  the 
system,  cocain,  novocain,  or  any  other  anesthetic  is  not  indicated.  It  is 
important  to  note  that  novocain  is  much  safer  than  other  drugs  of  this 
nature.  The  danger  of  injecting  in  a  pus-pocket  must  always  be 
borne  in  mind,  for  the  infection  can  easily  be  pressed  on  ahead  into 
sound  tissue.  The  injection  should  be  made  into  the  sound  tissues  and 
in  such  a  way  as  to  encircle  the  diseased  area,  or  the  nerve  to  be 
blocked. 

Danger  from  the  injection  of  cocain  or  its  substitutes  is  lessened 
by  limiting  the  general  absorption  of  the  injected  fluid,  which  may 
contain  very  poisonous  drugs.  We  have,  however,  a  good  working 
principle  to  go  by :  that  local  anemia  or  ischemia  prevents  the  rapid 
absorption  of  fluids  that  are  injected  into  a  circumscribed  area.  More- 
over, if  the  absorption  of  the  fluid  is  retarded,  there  results  an  increase 
in  the  local  action  of  the  poisonous  drugs ;  and  increased  local  action 
means  increased  local  consumption  of  the  poisonous  drugs,  and  conse- 
quently less  danger  from  general  absorption. 

Preparation  of  the  Anesthetic  Solution. — In  order  to  get  the 
best  results  from  the  injection  of  anesthetizing  drugs,  the  solution 
should  be  isotonic  with  the  body  fluids. 

Osmotic  pressure  is  a  physical  phenomenon  which  is  dependent 
on  the  number  of  molecules  of  salt  present  in  a  solution,  and  on 
their  power  of  dissociation.  Equal  osmotic  pressure  becomes  estab- 
lished when  the  salt  solution  is  of  the  same  concentration  on  each  side 
of  a  permeable  animal  membrane.  The  membrane  of  a  living  cell 
readily  absorbs  distilled  water,  but  if,  on  the  other  hand,  the  surround- 
ing fluid  is  a  highly  concentrated  salt  solution,  the  solution  absorbs 
water  from  the  cell ;  and  the  cell  shrinks  and  Anally  dies.  This  process 
is  called  necrobiosis. 

The  pain,  or  tissue  necrosis  that  frequently  follows  an  injection,  is 
usually  due  to  using  a  solution  that  is  not  isotonic  with  the  tissue 
fluids. 

By  means  of  another  physical  law  the  proper  concentration  of 
fluids  for  intracellular  injection  may  be  determined.  All  aqueous  so- 
lutions possessing  an  equal  freezing  point  have  equal  osmotic  pressure. 
A  physiological  salt  solution  which  at  body  temperature  has  the  same 
osmotic  pressure  as  the  tissue  fluids  can  be  injected  into  the  loose  con- 
nective tissues  under  the  skin  in  moderate  quantity,  and  neither  swelling 
nor  shrinking  of  the  cell  will  occur.  A  simple  wheal  will  form,  which 
causes  no  irritation,  and  consequently  no  pain  is  felt. 

A  solution  of  novocain  for  dental  purposes  may  be  prepared  as 
follows : 


LOCz\L.  ANESTHESIA.  679 

Novocain 7  grains   (0.45  Gm.). 

Sodium    chlorid    4  grains   (0.25   Gm.). 

Distilled  water    1  fluidounce  (30  C.c). 

Boil  the   solution. 

To  each  cubic  centimeter  add  one  drop  of  epinephrin  when  used. 

Ready-made  solutions  of  cocain  and,  to  some  extent,  of  novo- 
cain will  not  keep  when  frequently  exposed  to  the  air.  A  perfect 
sterile  solution  may  be  made  extemporaneously  by  dissolving  the  neces- 
sary amount  of  novocain-suprarenin  in  tablet  form  in  a  given  quantity 
of  boiling  physiological  salt  solution.  A  suitable  tablet  may  be  prepared 
as  follows :  , 

Novocain     14  grain   (0.015   Gm.). 

Suprarenin    hydrochlorid,    synthetic.  .%200   grain   (0.000054  Gm.). 


Fig.  448.  Large  and  small  porcelain  dissolving  cups  for  preparing  sterile  novocain 
Eohition. 

One  tablet  dissolved  in  20  minims  (1  cubic  centimeter)  boiling 
physiological  salt  solution  makes  a  ly^  per  cent  solution  of  novocain 
ready  for  immediate  use. 

Ready-made  sterile  tablets  of  the  above  or  a  similar  composition 
may  be  obtained  from  dental  supply  houses.  These  tablets  must  be 
carefully  protected  against  moisture  and  light. 

Solutions  for  hypodermic  purposes  should  be  made  fresh  when 
needed.  A  simple  porcelain  crucible  or  a  graduated  porcelain  dis- 
solving cup  (Fig.  448)  held  by  a  suitable  twisted  aluminum  tongue 
and  a  dropping  bottle  constitute  the  simple  outfit  for  this  work.  The 
dropping  bottle  should  hold  from  one  to  four  ounces.  A  groove 
on  one  side  of  the  neck  of  the  bottle  and  a  vent  on  the  other  con- 
nected with  two  grooves  in  the  back  of  the  stopper  allow  the  con- 
tents to  flow  out  drop  by  drop.     A  quarter  turn  of  the  stopper  closes 


680  SURGERY  OF  THE  MOUTH  AND  JAWS. 

the  bottle  tightly.  The  number  of  drops  present  in  each  cubic  centi- 
meter differs  with  the  various  sizes  of  the  dropping  bottles,  hence 
each  bottle  has  to  be  standardized  with  a  tested  minim  graduate  or  a 
tested  burette.  The  standard  number  of  drops  may  be  marked  on  the 
respective  bottle  with  a  carborundum  stone.     (Fig.  449.) 

The  hypodermic  solution  can  be  made  extemporaneously  in  a 
few  seconds  as  follows :  Place  a  tablet  in  the  porcelain  dissolving 
cup,  add  the  necessary  number  of  drops  (1  c.  c.)  of  physiological  salt 
solution,  and  boil  for  a  few  seconds  by  holding  the  cup  above  the 
flame  of  the  burner.     The  solution  is  now  ready   for  immediate  use. 


Fig.  449.  Glass  measure  for  local  anesthetics.  The  measure  is  marked  from  10, 
20,  30,  or  40  minims.  It  is  useful  for  measuring  anesthetic  solutions,  or  for  dissolving 
tablets    in   stipulated   quantities   of   liquids. 

Ready-made  sterile  solutions  of  local  anesthetics  are  also  sold  at 
present,  and  are  marketed  in  hermetically  sealed  ampuls  of  various 
designs.  To  open  the  ampul,  a  small  groove  is  made  with  a  file  at 
one  end,  which  is  then  readily  broken  off.  The  contents  are  aspirated 
by  inserting  the  syringe  provided  with  the  needle  directly  into  the 
opened  ampul.    (Fig.  450). 

The  practitioner  is  especially  cautioned  in  regard  to  the  use  of 
local  anesthetics  in  the  form  of  ready-made  solutions.  Solutions  of 
cocain,  even  when  rendered  sterile  by  fractional  sterilization,  will  not 
remain  so  after  the  contents  of  the  bottle  are  exposed  to  the  air  for  a 
short  time.  Ready-made  solutions  that  are  sold  in  the  shops  under 
more   or   less   fanciful    names   require    still    greater   precaution.      The 


LOCAL  ANESTHESIA. 


681 


Food  and  Drugs  Act  (1906)  and  more  recently  (1915)  the  Harrison 
Narcotic  Law,  require  that,  all  solutions  containing  cocain,  or  any 
substitute  thereof,  must  be  so  labeled.  Most  of  the  many  so-called  safe 
and  reliable  anesthetics  found  in  the  market  contain  cocain  or  its  sub- 
stitutes in  varying  quantities.  The  addition  of  epinephrin  to  a  ready- 
made  solution  not  only  destroys  this  alkaloid  in  a  very  short  time,  but 
the  products  of  its  decomposition  make  the  solution  still  more  danger- 
ous. The  printed  formulas  that  acccompany  many  of  the  ready- 
made  solutions  of  local  anesthetics  frequently  show  an  utter  disregard 
of  the  pharmacologic  action  of  the  individual  ingredients,  which 
forces  us  to  conclude  that  they  are  a  slur  on  the  intelligence  of  the 
practitioner  who  uses  such  compounds. 


Fig,     450.      Hermetically     sealed     glass     ampuls     of    various     types.      They     contain 
sterile  anesthetic  solutions. 


HYPODERMIC  ARMAMENTARIUM. 

In  order  to  successfully  inject  a  local  anesthesia,  it  is  important 
that  one  should  have  the  right  kind  of  a  hypodermic  syringe.  The  in- 
jection into  the  dense  gum  tissue  requires  from  15  to  50,  or  more, 
pounds  of  pressure,  as  registered  by  an  interposed  dynamometer,  while 
in  pressure  anesthesia  100,  or  more,  pounds  are  frequently  applied. 
After  making  a  thorough  test  of  most  of  the  dental  hypodermic  syringes 
offered  at  the  dental  depots  within  the  last  five  years,  by  means  of  the 
pressure  and  in  clinical  work,  we  recommend  the  all-metal  syringe  of 
the  "Imperial"  type.  They  are  usually  made  of  nickel-plated  brass, 
which,  however,  is  a  disadvantage,  as  the  nickel  readily  wears  from 
the  piston   and   exposes   the  brass.     It  holds   40  minims    (3.4  cubic 


682  SURGERY  OF  THE  MOUTH  AND  JAWS. 

centimeters),  and  is  provided  with  a  strong  finger  cross- 
bar. The  space  between  the  cross-bar  and  the  piston-tip  is  of 
importance,  as  it  allows  the  last  drop  of  the  fluid  to  be  expelled  under 
heavy  pressure  without  tiring  the  fingers.  The  syringe  described  is 
designed   for  injecting  under  considerable  pressure.     This   is  needed 


I'^ig.   451.      Thoma  sterilizer  for  hypodermic  syringes,  dissolving  cups,  etc. 

in  working  in  the  mucoperiosteum  of  the  gums  and  palate.  For  the 
ordinary  soft  tissues  such  great  pressure  is  not  needed.  But  the  con- 
nections should  be  tight,  and  they  should  be  able  to  withstand  consid- 
erable pressure.  Some  syringes  with  slipjoints  are  not  adapted  to 
infiltrating  even  the  skin,  because  the  force  necessary  will  dislodge 
the  needle  from  the  barrel.  For  injecting  a  small  amount  of  fluid,  the 
ordinary  hypodermic  will  suffice,  but  for  using  a  diluted  infiltrating 
solution,  it  is  more  convenient  to  use  a  syringe  that  will  hold  10  or  20 
cubic  centimeters  of  the  solution.  Regardless  of  the  type  of  syringe 
used,  it  should  be  so  constructed  as  to  stand  boiling.     In  using  a  dental 


LOCAL  ANESTHESIA.  683 

syringe  with  leather  packing,  the  latter  is  to  be  removed  before  boiling. 
For  infiltrating  the  skin,  a  very  fine  needle  is  preferable;  its  inser- 
tion causes  less  pain,  and  it  causes  less  laceration.  For  infiltrating  deep 
tissues,  a  coarse  needle  will  do  the  work  more  quickly  and  effectually. 
The  length  of  the  needle  should  be  adequate  to  the  work  in  hand. 


Pig.    452.      Novocain    armamentarium. 

TECHNIQUE  OF  INJECTION. 

The  anesthetic  may  be  forced  into  the  tissues  in  or  about  the  teeth 
in  the  following  ways : 

Subperiosteal  injection. 
Peridental  injection. 
Intraosseous  injection. 
Perineurial  injection. 
Injection  into  the  pulp. 
For  operating  on  the  soft  tissues,  the  solution  is  injected  directly 
into  the  tissues  to  be  cut,  or  around  the  sensory  nerves  supplying  the 


684  SURGERY  OF  THE  MOUTH  AND  JAWS. 

area.     For  operations  confined  to  a  small  area  of  mucous  membrane, 
local  application  of  a  strong  novocain  or  cocain  solution  is  permissible. 

Before  any  further  steps  have  been  taken,  the  field  of  operation 
should  be  thoroughly  cleansed  with  an  antiseptic  solution.  A  thin 
coat  of  the  diluted  tincture  of  iodin  painted  over  the  surface  is  very 
good  for  this  purpose.  After  the  diagnosis  has  been  made,  the  method 
of  injection  is  determined.  The  anesthetic  solution  should  now  be 
prepared,  and  the  syringe  and  needle  made  ready  for  use. 

The  hand  holding  the  syringe  is  governed  by  the  wrist  so  as  to  allow 
delicate  and  steady  wrist  movements,  and  the  fingers  must  be  trained 
to  a  highly  developed  sense  of  touch.  The  syringe  is  filled  by  drawing 
the  solution  into  it;  it  is  held  perpendicularly,  point  up,  and  the  piston 
is  pushed  in  until  the  first  drop  appears  at  the  needle  point,  which  pre- 
caution prevents  the  injection  of  air  into  the  tissues. 

Subperiosteal  Injection. — The  success  of  this  injection  depends 
upon  the  penetration  of  the  fluid  into  the  bone  and  thus  reaching  the  con- 
tained nerves'.  The  subperiosteal  injection  about  the  root  of  an  anterior 
tooth  is  best  started  by  inserting  the  needle  midway  between  the  gin- 
gival margin  and  approximate  location  of  the  apex.  The  pain  of  the 
first  puncture  may  be  lessened  by  a  very  fine  needle,  by  the  compres- 
sion of  the  gum  with  the  finger  tip,  by  holding  a  bit  of  cotton  saturated 
with  the  prepared  anesthetic  solution  on  the  gum  for  a  few  moments, 
or  by  applying  a  small  drop  of  liquid  phenol  on  the  point  of  puncture. 
The  needle  opening  faces  the  bone,  and  the  syringe  is  held  at  an  acute 
angle  with  the  long  axis  of  the  tooth.  After  puncturing  the  mucosa,  a 
drop  of  the  liquid  is  immediately  deposited,  rendering  further  injection 
painless.  As  the  needle  is  forced  along  the  alveolar  bone  toward  the 
apex  of  the  tooth,  the  liquid  is  deposited  under  pressure  close  to  the 
bone  on  its  upward  and  return  trip.  The  continuous  slow  moving  of 
the  needle  prevents  injecting  into  a  vein.  A  second  injection  may  be 
made  by  partially  withdrawing  the  needle  from  the  puncture  and 
swinging  the  syringe  anteriorly  or  posteriorly  from  the  first  route 
(Figs.  453  and  454).  After  removing  the  needle,  place  the  finger  tip 
over  the  puncture  and  gently  massage  the  injected  area.  No  wheal 
should  be  raised  by  the  fluid,  as  that  would  indicate  superficial  infll- 
tration  and  failure  of  the  anesthetic.  Five  to  ten  minutes  should  be 
allowed  before  the  extraction   is  started. 

The  upper  eight  anterior  teeth  usually  require  a  labial   injection 

only,  while  the  molars  require  botli  a  buccal  and  a  palatine  injection. 

The   lower   molars   require  a   buccal   and   lingual   injection.     The 

curved  needle  is  inserted  midway  between  the  roots,  the  gum  margin, 

and   the  apices.     The  external   and   internal  oblique   lines   materially 


LOCAL  ANESTHESIA. 


685 


hinder  the  ready  penetration  of  the  injected  fluid,  and  therefore  ample 
time  should  be  allowed  for  its  absorption. 

The  injection  into  inflamed  tissue,  into  an  abscess,  and  into  phleg- 
monous infiltration  about  the  teeth  is  to  be  avoided.  The  injection 
into  engorged  tissues  is  very  painful.  The  dilated  vessels  quickly 
absorb  the  anesthetic  without  producing  a  complete  anesthesia,  and 
poisoning  may  result.  In  purulent  conditions  the  injection  is  de- 
cidedly dangerous,  as  it  may  force  the  infection  beyond  the  line  of  de- 
marcation.    If  the  abscess  presents  a  definite  outline,  the  injection  has 


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Fig.    454 


Fig.   455. 


Fig.   456. 


Pig.  45.3. 
Fig.   454. 
Fig.   455. 
After  Prinz. 
Fig.    456. 


Subperiosteal     injection     of    a    canine     tootli. — After    Prinz. 

Subperiosteal   injection   of  a  molar  tooth. — After   Prinz. 

Subperiosteal,   peridental,   and   intraosseus   injection   of   a   canine  tooth. — 

Peridental    injection   of    a    bicuspid    tooth. — After    Prinz. 

to  be  made  into  the  sound  tissue  surrounding  the  focus  of  infiltration. 
If  a  tooth  is  affected  with  acute,  diffuse,  or  purulent  pericementitis,  a 
distal  and  a  mesial  injection  usually  produces  successful  anesthesia  by 
blocking  the  sensory  nerve  fibers  in  all  directions. 

Peridental  Injection. — This  simple  method,  which  consists  in  in- 
jecting the  anesthetic  by  means  of  a  fine,  short  needle  into  the  peridental 
membrane  between  the  tooth  and  the  alveolar  wall,  is  a  most  satisfac- 
tory method  of  anesthetizing  teeth  standing  singly,  or  teeth  affected  by 
some  chronic  peridental  disturbance.  To  accomplish  this,  separation 
of  the  teeth  is  often  necessary.  The  injection  is  usually  repeated  two 
or  three  times.     A  higher  pressure  is  used  than  in  the  former  method, 


686  SURGERY  OF  THE  MOUTH  AND  JAWS. 

but  the  amount  of  fluid  used  is  much  less.  The  results  are  extremely 
satisfactory,  and  this  method  should  be  used  whenever  conditions  jus- 
tify it  (Fig-s.  455  and  456). 

Intraosseous  Injection. — In  1896,  Otte  recommended  this  meth- 
od, by  which  he  forces  the  anesthetic  solution  directly  into  the  spongy 
cancellous  bone.  This  is  more  direct  and  more  certain  of  result  than 
subperiosteal  injection.  To  do  this,  the  gum  tissue  must  be  anes- 
thetized above  the  neck  of  the  tooth,  in  the  same  manner  as  outlined 
under  subperiosteal  injection.  Then  an  opening  is  made  into  the  bone 
on  the  buccal  side  with  a  fine  spear  drill  or  a  Gates-Glidden  drill.  The 
opening  should  be  made  more  or  less  at  a  right  angle  with  the  long  axis 
of  the  tooth,  a  little  below  the  apical  foramen  in  single-rooted  teeth,  or 
between  the  bifurcation  in  the  molars.  The  right-angle  hand  piece  is 
preferably  employed  for  this  purpose.  The  drill  should  be  of  the  same 
diameter  as  the  hypodermic  needle.  The  gum  fold  is  tightly  stretched 
to  avoid  laceration  from  the  rapidly  revolving  drill.  As  soon  as  the 
alveolar  process  is  penetrated,  a  peculiar  sensation  conveyed  to  the 
guiding  hand  indicates  that  the  alveolus  proper  is  reached,  and  the  sen- 
sation felt  by  the  hand  is  about  the  same  as  that  experienced  when  a 
bur  enters  into  the  pulp  chamber.  In  this  artificial  canal  the  close- 
fitting  needle  of  the  hypodermic  syringe  is  now  inserted,  and 
the  injection  is  made  in  the  ordinary  way.  The  quantity  of  fluid  used 
is  much  less  than  is  usually  needed  for  a  subperiosteal  injection.  The 
roots  of  the  teeth  are  imbedded  in  a  sieve-like  mass  of  bone  tissue 
(diploe),  which  allows  a  ready  penetration  of  fluid  when  injected  under 
pressure.  Very  recently,  Masselink  advocated  this  method  for  the 
anesthetization  of  any  tooth  in  the  mouth,  either  for  the  purpose  of 
extraction  or  the  removal  of  its  pulp.  He  employs  a  No.  3^  round 
bur  for  penetrating  the  alveolar  plate  and  a  very  short  needle  (one 
sixteenth  of  an  inch)  with  a  dull  point  for  injection  (Fig.  455). 

Perineurial  Injection. — When  a  number  of  teeth  or  a  large  area 
is  to  be  anesthetized,  this  method  is  preferable.  It  consists  in  injecting 
the  fluid  about  the  nerve  trunks  at  some  convenient  point  to  block 
afiferent  impulses.  All  the  teeth  of  one  half  of  the  upper  jaw  can  be 
anesthetized  by  four  injections — two  buccally,  and  two  on  the  palatine 
side  of  the  bone.  A  one-inch  needle  is  required  for  this  work  (Fig. 
457). 

(1)  To  reach  the  many  small  branches  of  the  posterior  dental 
nerves  at  the  alveolar  foramina,  the  injection  is  made  buccally  above 
the  region  of  the  tuberosity,  about  one-half  inch  above  the  gingival 
line,  the  needle  entering  between  the  first  and  second  molar  tooth,  and 
being  pushed  upward  and  backward  close  to  the  bone, 

(2)  The  second  injection  is  made  below  the  infraorbital  foramen. 


LOCAL  ANESTHESIA. 


687 


SO  as  to  reach  the  middle  and  anterior  dental  nerves.  With  the  index 
finger  of  the  left  hand,  the  foramen  is  approximately  located  by  ex- 
erting pressure  upon  the  nerve-exit.  The  lip  is  lifted  up  with  the 
middle  finger  of  the  same  hand,  and  the  needle  is  now  inserted  between 
the  apices  of  the  canine  and  the  first  biscuspid  teeth.  The  needle  is 
slowly  pushed  upward  until  its  point  is  felt  beneath  the  finger  tip. 

(3)  The  nerves  of  the  palate  are  blocked.  Clinical  observation  has 
taught  that  the  teeth  are  sensitized,  not  only  through  their  proper  max- 
illary nerves,  but  also  through  branches  of  the  fifth  nerve  distributed 
to  the  neighboring  soft  tissue.  In  the  upper  jaw  the  posterior  palatine 
and  nasopalatine  nerves  must  be  controlled. 

(4)  To  anesthetize  one  half  of  the  mandible,  three  injections  are 
necessary:  the  first  near  the  mandibular  foramen,  the  second  near  the 


Fig.  457.  Subperiosteal  and  perineuria!  injection  for  the  control  of  the  dental 
branches  of  the  maxillary  nerve. — After  Prlnz.  A,  point  of  insertion  of  the  needle  in 
the  gum.     B,  point  at  which  the  injection  is  made. 


mental  foramen,  and  the  third  into  the  incisive  fossa.  The  injection  of 
the  lingual  nerve  with  the  inferior  dental  will  obviate  the  latter  in- 
jection. 

The  technique  for  injecting  the  various  nerves  about  the  jaw  was 
given  under  the  Treatment  of  Neuralgia.  ' 

Anesthetization  of  the  Pulp. — By  pressure  anesthesia,  pressure 
cataphoresis,  or  contact  anesthesia,  as  the  process  is  variously  termed, 
we  understand  the  introduction  of  a  local  anesthetizing  agent  in  solu- 
tion by  mechanical  means  through  the  dentin  into  the  pulp  for  the 
purpose  of  rendering  this  latter  organ  insensible  to  pain.  Simple 
hand-pressure  with  a  suitable  instrument,  the  hypodermic  syringe  or 
the  so-called  "high  pressure"  syringe,  is  recommended  for  such  pur- 
poses.    A  liquid  cannot  be  forced  through  healthy  dentin  by  a  me- 


688  SURGERY  OF  THE  MOUTH  AND  JAWS. 

chanical  device  without  injury  to  the  tooth  itself.  If  a  cocain  solution 
is  held  in  close  contact  with  the  protoplasmic  fibers  of  the  dentin,  the 
absorption  of  cocain  takes  place  in  accordance  with  the  law  of  osmosis. 
By  drying  out  the  dentin  and  then  confining  the  anesthetic  solution 
under  a  water-tight  cover,  the  pressure  applied  by  the  finger  is  suffi- 
cient to  obtain  results.  In  teeth  not  fully  calcified  and  in  so-called 
"soft"  teeth,  pressure  anesthesia  is  more  readily  obtained,  while,  ac- 
cording to  Zederbaum,  the  process  fails  in  teeth  of  old  persons,  teeth 
of  inveterate  tobacco  chewers,  worn,  abraded,  and  eroded  teeth,  teeth 
with  extensive  secondary  calcific  deposits,  teeth  whose  pulp  canals  are 
obstructed  by  pulp  nodules,  teeth  with  metallic  oxids  in  tubules,  teeth 
with  leaky  fillings,  mainly  all  from  one  and  the  same  cause — namely, 
clogged  tubules.  In  most  of  these  cases  no  amount  of  persistent 
pressure  will  prove  successful. 

From  the  foregoing,  it  will  be  observed  that  the  so-called  "high 
pressure"  syringes  possess  no  special  merit  relative  to  pressure  anes- 
thesia. A  good  all-metal  syringe  can  be  made  to  produce  from  25 
to  50  pounds  pressure ;  this  is  much  greater  than  is  needed  in  the 
ordinary  forms  of  pressure  anesthesia. 

Methods. — (1)  The  pulp  is  wholly  or  partially  exposed.  Ex- 
cavate the  cavity  as  much  as  possible,  and  if  the  pulp  is  not  plainly 
exposed,  dehydrate  with  alcohol  and  hot  air.  Saturate  a  pledget  of 
cotton  with  a  concentrated  cocain  or  novocain  solution,  place  it  in  the 
cavity,  cover  it  with  vulcanizable  rubber,  and  with  a  suitable  burnisher 
apply  slowly  increasing,  continuous  pressure  from  one  to  three  minutes. 
Now  expose  the  pulp  and  test  it.  If  it  is  still  sensitive,  repeat  the 
process. 

(2)  The  pulp  is  covered  with  a  thick  layer  of  healthy  dentin.  With 
a  very  small  spade  drill  bore  through  the  enamel  or  directly  into  the 
dentin  at  a  most  convenient  place,  guiding  the  drill  in  the  direction  of 
the  pulp  chamber.  Blow  out  the  chips,  dehydrate  with  alcohol  and 
hot  air,  and  apply  the  syringe,  provided  with  a  special  needle,  making 
as  nearly  as  possible  a  water-tight  joint.  Apply  slow,  continuous  pres- 
sure from  two  to  three  minutes.  With  a  round  bur  the  pulp  should 
now  be  exposed,  and  if  still  found  sensitive,  the  process  is  to  be  re- 
peated. The  intraosseous  or  peridental  injection  is  the  most  practical 
method  of  anesthetization  of  the  pulps. 

The  anesthetizing  of  the  peridental  membrane  for  the  treatment  of 
pyorrhea  alveolaris  is  a  com'paratively  simple  matter,  if  carried  out 
according  to  the  methods  as  outlined  under  the  heading  of  Peridental 
Anesthesia.  Sometimes  a  topical  application  of  a  fairly  concentrated 
novocain-adrenalin  solution  (about  10  per  cent),  applied  to  the  pockets 
by  means  of  cotton  ropes,  accomplishes  the  desired  purposes.     The  care- 


LOCAL  ANESTHESIA.  689 

ful  application  of  10  per  cent  cocain  on  small  cotton  wisps  left  in  place 
for  ten  minutes  is  more  efficacious.  This  solution  should  not  be 
allowed  to  drip  into  the  mouth.  The  surgical  treatment  of  pyorrhea 
is  materially  simplified,  if  the  tissues  under  consideration  are  relieved 
of  sensation. 

LOCAL  ANESTHESIA  FOR   OPERATIONS   ABOUT 
THE  MOUTH. 

For  opening  the  antrum,  a  submucous  and  subperiosteal  injection 
is  made  with  a  2  per  cent  novocain  solution  over  an  appropriate  area  in 
the  canine  fossa,  and  sufficient  time  is  allowed  for  the  solution  to  diffuse 
through  the  bone  before  the  operation  is  begun. 

For  very  small  incisions  a  1  or  2  per  cent  solution  may  be  used,  but 
if  a  large  area  is  to  be  anesthetized  by  direct  infiltration,  a  much  weaker 
solution  must  be  used.  Schleich  popularized  the  use  of  weak  cocain 
solutions  in  large  quantity,  put  in  under  pressure.  We  have  modified 
his  solution  by  the  substitution  of  novocain  and  the  addition  of  adrena- 
lin. The  following  solution  will  be  found  effective  in  most  people, 
and  can  be  used  in  a  relatively  unlimited  quantity : 

Sodium     chlorid,       0.25 
Novocain,  0.06 

Water,  q.  s.  ad.,  32.0 
Boil. 

If  any  water  is  lost  by  boiling,  it  is  made  up  by  the  addition  of  sterile 
water.  To  each  10  cubic  centimeters  of  the  anesthetizing  solution, 
when  cooled,  is  addel  one  minim  of  a  1 :1000  solution  of  adrenalin 
chlorid.  The  latter  salt  will  not  stand  boiling,  and  the  solution  spoils 
soon  after  it  is  added. 

It  is  most  important  that  the  skin  is  perfectly  anesthetized.  Few  of 
the  subcutaneous  tissues  are  sensitive  to  cutting,  although  they  are 
sensitive  to  crushing,  pulling,  or  tearing.  It  is  practical,  for  instance, 
after  anesthetizing  the  skin,  to  do  such  an  extensive  operation  as  re- 
moving a  goiter  with  but  little  pain. 

To  anesthetize  the  skin,  a  fine  needle  is  inserted  obliquely  into  the 
substance  of  the  skin,  the  injection  being  made  with  great  pressure. 
The  needle  should  not  penetrate  the  skin,  but  the  point  should  remain 
in  its  substance.  When  the  injection  is  made,  the  skin  turns  white 
and  rises  up  in  an  elevated  circular  papule,  which  has  an  uneven 
pitted  surface.  If  the  needle  has  completely  penetrated  the  skin,  the 
fluid  is  deposited  beneath  it,  and  its  appearance  remains  unchanged. 
When  the  white  papule  is  the  size  of  a  dime  or  a  nickel,  the  needle 
is  withdrawn  and  inserted  in  one  edge  of  the  papule,  and  the  injection 


690  SURGERY  OF  THE  AIOUTH  AND  JAWS. 

is  repeated;  or  if  the  needle  is  of  sufficient  length,  it  is  simply  pushed 
in  intracutaneously  to  a  new  area.  This  is  known  as  Schleich's  method. 
The  mucous  membrane  can  be  anesthetized  in  the  same  way  or  by 
simply  painting  the  surface  with  a  5  to  20  per  cent  cocain  or  novocain 
solution,  depending  upon  the  size  of  the  area.  The  deeper  tissues 
are  infiltrated  with  a  coarser  needle  that  penetrates  to  various  depths. 

After  injecting  the  line  of  the  superficial  incision,  the  tissues  to  be 
invaded  should  be  entirely  surrounded  by  the  solution. 

To  open  an  abscess  that  is  covered  by  a  layer  of  non-infiltrated 
tissue,  the  latter  is  injected  with  the  anesthetizing  solution,  but  the 
injection  should  not  be  made  into  the  abscess  or  indurated  tissue.  Be- 
sides being  a  source  of  danger,  the  injection  is  more  painful  than  an 
incision  with  a  sharp  knife.  Spraying  the  surface  with  ethyl  chlorid 
is  here  more  satisfactory. 

The  most  satisfactory  application  for  perineurial  injections  is  in 
operating  on  the  body  of  the  tongue,  or  on  the  body  of  the  lower  jaw. 
Theoretically  one  should  be  able  to  inject  either  the  second  or  third 
division  of  the  fifth  nerve  where  they  emerge  from  foramina  of  exit, 
and  thus  completely  anesthetize  the  whole  area  of  the  face.  We  have 
not  been  able  to  do  this  with  any  certainty  in  practice.  (For  the  tech- 
nique of  making  perineurial  injection  in  the  face  and  mouth,  see  Injec- 
tion of  the  Trunks  and  Branches  of  the  Fifth  Nerve,  Chap.  XLIV.) 
Usually  from  1  to  2  cubic  centimeters  of  a  2  per  cent  novocain  solution 
are  used  about  the  nerve,  and  when  successful,  10  to  15  minutes  elapse 
before  the  anesthesia  appears  over  the  area  guarded  by  the  nerve. 


CHAPTER  XLVI. 

GENERAL  ANESTHESIA. 

The  anesthetic  agent  and  the  method  of  administration  should  al- 
ways be  a  matter  of  selection  for  the  individual  patient  in  hand. 
Nitrous  oxid  with  oxygen  presents  the  slightest  element  of  danger; 
chloroform  the  greatest. 

The  anesthesia  should  be  conducted  by  a  trained  anesthetist,  and 
there  is  a  distinct  advantage  in  reciprocal  confidence  between  anes- 
thetist and  operator.  The  preliminary  and  immediately  subsequent 
care  of  the  patient,  so  far  as  concerns  the  anesthesia,  should  be  in  the 
hands  of  the  anesthetist. 

Forty-five  minutes  before  the  induction  of  anesthesia,  the  patient 
should  be  given  ^  grain  of  morphin  sulphate  with  Viso  grain  of 
atropin  sulphate,  hypodermatically.  In  young  children  and  infants  this 
is  omitted,  and  the  dose  is  modified  in  elderly  people.  The  induction 
should  occur  under  every  possible  consideration  of  the  mental  attitude 
of  the  patient. 

The  careful  selection  of  the  anesthetic  agent  does  not  release  the 
anesthetist  from  continued  attention  to  that  feature  of  his  work.  In 
occasional  instances  danger  signals  present  themselves ;  and  a  correct 
interpretation  makes  it  obligatory  upon  the  anesthetist  to  change  to  the 
drug  more  closely  adapted  to  that  particular  patient.  It  is  an  essential 
part  of  the  anesthetist's  duty  to  see  that  the  patient  is  properly  pro- 
tected by  clothing,  that  the  position  will  not  cause  danger,  and  that  the 
larynx  is  kept  free  from  blood  and  mucus. 

CHLOROFORM. 

The  use  of  chloroform  should  probably  be  restricted  to  patients 
presenting  pulmonary  lesions  that  would  be  aggravated  by  ether.  This 
drug  should  be  given  by  the  drop  method  with  a  widely  open  mask. 
The  sudden  deaths  that  occasionally  occur  under  chloroform  might  in 
some  cases  have  been  avoided  by  starting  the  anesthetic  more  gradu- 
ally. The  parenchymatous  degeneration  that  may  follow  chloroform 
anesthesia,  especially  in  septic  patients,  can  be  prevented  only  by  ab- 
staining from  its  administration.  Chloroform  should  never  be  used 
in  conjunction  with  cocain  and  adrenalin. 

691 


692  SURGERY  OF  THE  MOUTH  AND  JAWS. 

ETHER. 

Ether  is  ordinarily  given  by  the  drop  method  on  the  usual  wire 
mask  covered  with  eight  to  ten  layers  of  gauze.  The  mask  is  sur- 
rounded with  a  wet  towel. 

The  primary  advantage  of  the  open  drop  method  is  safety  to  the 
patient  because  of  the  wide  limit  between  surgical  anesthesia  and 
death.  The  surgeon  in  this  method  has  a  means  of  anesthesia  which 
is  certain  in  its  action,  which  requires  no  cumbersome  or  expensive 
apparatus,  which  can  practically  always  be  obtained,  and  which,  in 
case  of  absolute  necessity,  can  be  administered  by  an  untrained  as- 
sistant. 


Fig.  458.  The  Rupert  apparatus  for  the  administration  of  ether  vapor  spray.  The 
metal  container  for  heating  the  ether  holds  the  ether  bottle  firmly  in  position  and  permits 
the  water  to  be   renewed   at  will. 

The  dangers  of  the  open  drop  method  are :  asphyxiation  from  the 
aspiration  of  stomach  contents,  injury  to  the  parenchyma  of  important 
organs,  the  general  lowered  resistance  of  the  patient  to  shock  and  in- 
fection, and,  most  important  of  all,  the  frequency  with  which  its 
administration  is  followed  by  inflammations  of  the  respiratory  tract. 

Ether  Vapor  Spray  is  administered  by  some  form  of  apparatus 
which  forces  ether  vapor  to  the  oral  or  nasal  cavity  for  the  purpose 
of  continuing  general  anesthesia.  The  apparatus  for  its  administra- 
tion should  have  the  following  parts :  An  ether  bottle  in  which  the 
vapor  is  produced ;  a  firm  container  for  hot  water  in  which  the  ether 
bottle  is  placed  to  cause  the  formation  of  ether  vapor;  an  intake  for 


GENERAL  ANESTHESIA. 


693 


air  under  pressure,  and  an  outlet  for  the  vapor  from  the  ether  bottle ; 
a  hand  air  pressure  bulb,  tubing,  and  an  outlet  tube  at  the  end  of 
which  is  a  hollow  metal  director  for  the  vapor.  The  Rupert  appa- 
ratus (Fig.  458)   has  been  used  by  us  with  perfect  satisfaction. 

The  advantages  of  this  method  are  that  the  anesthetist  is  out  of 
the  way  of  the  operator  and  by  means  of  a  specially  devised  end  piece 
may  even  assist  him.  It  is  the  method  which  entails  less  danger  to 
the  patient  than  any  other  form  of  ether  inhalation  anesthesia.  It 
has  one  great  disadvantage;  it  is  impossible  to  maintain  surgical 
anesthesia  in  robust  individuals.  This  has  led  to  a  decided  restriction 
in  its  indications.     For  adults,  intratracheal  insufflation  answers  every 


Fig.  459.  The  Richardson  apparatus  for  Intratracheal  anesthesia.  Under  forced 
pumping  with  dental  foot  pump  a  maximum  of  37  mm.  of  mercury  was  delivered 
through  the  outlet  tube.  Safe,  portable  and  nothing  to  get  out  of  order  ;  the  container 
is  an  ordinary  Mason  jar. 

indication  better  than  ether  vapor  spray,  but  in  extensive  operations 
about  the  nasal  or  oral  orifices  in  children  and  especially  in  infants 
no  other  method  has  proved  so  satisfactory. 


INTRATRACHEAL  OR  INSUFFLATION  ANESTHESIA. 

This  is  of  inestimable  value  in  operations  about  the  head  and 
neck.  Richardson's  apparatus  (Fig.  459)  is  by  far  the  simplest  and 
is  entirely  satisfactory.  The  patient  having  been  first  profoundly 
anesthetized  by  the  open  drop  method,  has  his  jaws  widely  opened  with 
a  mouth  gag.     The  anesthetist  stands  on  the  patient's  right,  inserts 


694 


SURGERY  OF  THE  MOUTH  AND  JAWS. 


the  forefinger  deep  into  the  pharynx  and  palpates  the  epiglottis.  The 
catheter,  previously  lubricated  with  vaselin,  projects  from  one  to 
two  inches  beyond  the  end  of  the  introducer.  The  tip  of  the  catheter 
is  now  guided  into  the  larynx  by  the  finger  of  the  left  hand.  After  the 
introduction  of  the  tip,  the  anesthetist  steadies  the  introducer  with  the 
right  hand,  while  an  assistant  gently  pushes  the  catheter  into  the 
trachea.  As  the  catheter  slips  into  the  trachea  the  patient  coughs.  This 
cough  is  so  typical  that  we  have  come  to  rely  upon  it  as  an  indication 
as  to  whether  the  catheter  is  in  the  trachea  or  has  slipped  back  into 
the  esophagus.  The  catheter  is  introduced  its  full  length  before  the 
introducer  is  slipped  out  over  it  and  then  if  necessary  the  catheter  is 


C 

i^  V 

1 

■f 

i 

1 

3 

^.'i* 

* 

'    k 

Fig.     4G0.      The     armamentaiiuui    essential     to     the     successful     use     of     iiifiltratiou 
auesthesia. 


slightly  withdrawn  until,  for  the  average  case,  three  inches  project 
beyond  the  teeth.  The  tube  from  the  ether  bottle  is  attached  directly 
to  the   catheter  and   the  (jperation   can  Ije  begun  at  once. 

The  values  of  this  type  of  anesthesia  arc  that  it  is  peculiarly  adapted 
to  operations  about  the  oral  and  nasal  cavities  inasnnich  as  there 
is  a  constant  stream  of  air  and  vapor  blowing  out  from  the  larynx, 
which  prevents  the  influx  of  saliva,  mucus  and  blood,  and  the  anesthet- 
ist is  entirely  removed  from  the  field  of  operation.  The  disadvantage 
of  this  type  of  anesthesia  is  that  in  some  cases  the  catheter  cannot 
be  introduced  into  the  larynx.     In  such  cases  it  is  permissible  to  per- 


GENERAL  ANESTHESIA.  695 

form  tracheetomy  in  order  to  make  the  use  of  insufiflation  anesthesia 
possible. 

NITROUS  OXID. 

Nitrous  oxid  alone  or  in  combination  with  oxygen  should  never 
be  administered  except  by  an  experienced  anesthetist.  Its  application 
in  plastic  surgery  of  the  head  and  face  is  limited  to  momentary  opera- 
tions. 

INFILTRATION   ANESTHESIA. 

Second  only  to  either  in  its  various  modes  of  administration  to 
produce  surgical  anesthesia  is  novocain.  The  great  impetus  given  to 
local  anesthesia  has  been  due  to  the  ideal  qualifications  of  this  drug 
for  anesthetic  purposes.  It  is  a  white  crystalline  powder  of  neutral 
reaction;  soluble  in  equal  parts  of  water,  it  can  be  heated  to  120° 
centigrade  without  decomposition.  Its  solutions  are  capable  of  re- 
peated boilings  and  it  will  keep  for  several  months  without  deteriora- 
tion. Its  physiologic  action  on  nerves  is  the  same  as  that  of  cocain 
and  its  derivaties.  There  is  no  local  irritation  to  the  tissues  even  from 
concentrated  solutions.  Its  toxicity  relative  to  cocain  is  one-fifth  to 
one  seventh,  while  its  anesthetic  value  when  combined  with  adrenalin 
quite  equals  that  of  cocain  for  any  strength  solution ;  when  combined 
with  adrenalin  it  may  for  practical  purposes  be  considered  non-toxic. 

In  the  successful  use  of  novocain  by  infiltration  the  size  of  the 
syringe  and  the  length  of  the  infiltrating  needle  are  the  most  important 
factors  (Fig.  460).  The  syringe  should  hold  10  cubic  centimeters  of 
solution,  and  the  needle  should  be  approximately  3  inches  long.  The 
method  of  infiltrating  for  various  operations  was  first  placed  on  a 
firm  scientific  basis  by  Braun ;  and  while  his  technique  is  by  no  means 
the  only  satisfactory  one,  yet  it  is  so  complete  that  if  closely  followed 
favorable  results  are  certain.  The  solution  ordinarily  used  is  0.5 
per  cent  novocain  in  normal  salt  solution  with  the  addition  of  3  drops 
of  adrenalin  chlorid,  1 :1000  to  each  ounce  of  solution.  Wherever 
possible  the  tissues  in  the  immediate  operative  field  are  blocked  off 
by  surrounding  them  by  an  infiltrated  zone  of  the  anesthetic  solution. 
This  method  does  not  distort  the  tissues  through  which  the  dissection 
must  be  made,  and  in  case  the  operative  field  must  unexpectedly  be 
enlarged,  the  infiltrated  zone  is  usually  great  enough  to  allow  prolonga- 
tion  of  the   incision   without  stopping   for  reinjection. 

Whenever  the  extent  of  the  operation  makes  the  above  method  im- 
practicable, nerve  blocking  is  resorted  to  by  infiltrating  the  tissue 
about  the  nerve  trunks  which  supply  the  affected  regions.  Frequently 
the  two  methods  are  combined. 


696  SURGERY  OF  THE  MOUTH  AND  JAWS. 

The  most  satisfactory  application  for  perineurial  injections  is  in 
operating  on  the  body  of  the  tongue,  or  on  the  body  of  the  lower  jaw. 
Theoretically  one  should  be  able  to  inject  either  the  second  or  third 
division  of  the  fifth  nerve  where  they  emerge  from  foramina  of  exit, 
and  thus  completely  anesthetize  the  whole  area  of  the  face.  We  have 
not  been  able  to  do  this  with  any  certainty  in  practice.  Usually  from 
1  to  2  cubic  centimeters  of  a  2  per  cent  novocain  solution  are  used 
about  the  nerve,  and  when  successful,  10  to  15  minutes  elapse  before 
the  anesthesia  appears  over  the  area  guarded  by  the  nerve. 

In  the  use  of  plastic  flaps  to  repair  defects  of  the  face  it  is  never 
necessary  to  use  a  general  anesthetic.  The  flap  to  be  raised  is  first 
outlined  by  scratching  the  skin  with  a  sharp  knife.  At  appropiate 
points  intradermal  injections  are  made  with  a  fine  needle  to  raise 
anesthetic  wheals  through  which  the  large  needle  is  inserted ;  the  flap 
area  is  then  blocked  off  by  subcutaneous  injections  which  connect  the 
wheals.  If  the  flap  is  to  be  raised  from  the  neck,  it  is  advisable  to  block 
the  cutaneous  branches  of  the  cervical  plexus  by  a  line  of  infiltration 
along  the  posterior  border  of  the  sternomastoid  muscle.  The  borders 
of  the  defect  which  are  drawn  inward  and  distorted  by  scar  contrac- 
tion are  anesthestized  by  massive  infiltration  directly  into  the  tissue  to 
be  raised.  In  the  use  of  the  novocain-adrenalin  solution  by 
infiltration  the  operator  must  always  remember  that  for  complete 
anesthesia  of  the  parts  from  ten  to  twenty  minutes  must  elapse  be- 
tween the  completion  of  the  injection  and  the  incision  of  the  tissues. 


APPENDIX. 

The  best  records  of  the  experiences  from  the  war  zone  enable  us 
to  formulate  the  following  in  regard  to  the  treatment  of  such  wounds  as 
are  likely  to  be  encountered  there. 

1.     Wounds  of  the  Soft  Tissues  Alone. 

(a)  Wounds  above  the  Lozuer  Border  of  the  Mandible. — When 
these  are  seen  early,  they  should  be  sewn  up,  possibly  with  the  appli- 
cation of  an  antiseptic.  Even  where  there  is  moderate  loss  of  tissue, 
undermining  of  flaps  might  be  practiced  with  provision  for  drainage  of 
the  undermined  spaces.  In  section  of  the  parotid  duct  provision  for 
drainage  of  the  saliva  into  the  mouth  must  be  made. 

(b)  Wounds  of  the  Neck. — Here  there  are  two  zones  of  especial 
danger  in  reference  to  subsequent  sepsis :  the  deep  subfacial  spaces  that 
lead  from  the  neck  to  the  thorax,  and  axilla  and  the  carotid  sheath 
when  some  branch  of  the  carotid  artery  has  been  ligated.  Superficial 
wounds  may  be  sutured  in  any  part,  usually  with  provision  for  drain- 
age. Deep  wounds  may  be  sutured  in  their  upper  part,  but  in  the 
lower  part  of  the  wound  the  deep  tissue  spaces  that  have  been  opened 
should  be  lightly  packed  off  with  iodoform  or  some  other  antiseptic 
gauze  to  block  off  communication  with  mediastinal  and  axillary  spaces. 
These  packs  should  not  be  large  or  tight,  but  should  enter  the  deepest 
part  of  the  open  spaces.  In  wounds  involving  the  carotid  sheath  or 
submaxillary  region  in  which  one  of  the  primary  branches  of  the  ex- 
ternal carotid  artery  has  been  ligated,  to  lessen  the  danger  of  secondary 
hemorrhage,  drainage  of  the  immediate  area  of  ligature,  preferably  by 
a  packing  of  gauze,  should  be  done. 

If  the  trachea  or  larynx  is  opened,  the  air  tube  may  be  partly  closed 
by  suture,  but  the  part  of  the  wound  superficial  to  the  air  tube  open- 
ing should  be  packed  to  encourage  drainage  away  from  and  not  into 
the  air  tube. 

A  wound  of  the  pharynx  or  esophagus  should  be  immediately 
sutured,  and  this  suture  line  covered  by  some  other  tissue,  but  the 
fascial  space  should  be  packed  in  its  lower  part  to  its  full  depth. 

Wounds  involving  the  full  thickness  of  the  floor  of  the  mouth 
should  not  be  sutured.  The  part  of  the  wound  above  the  lower  border 
of  the  mandible  should,  where  possible,  be  closed ;  but  below  the  mandi- 
ble the  wound  in  the  floor  of  the  mouth  should  be  packed,  preferably 
with  iodoform  gauze  and  balsam  of  peru. 

(597 


698  SURGERY  OF  THE   MOUTH  AND  JAWS. 

If  the  wound  is  of  such  extent  as  to  allow  the  tongue  to  fall  out  of 
the  mouth,  for  example — such  as  tearing  across  in  front  of  its  anterior 
midline  connections — repair  may  be  made  in  the  midline,  but  the  carotid 
space  should  be  protected  by  packing  in  the  lateral  part  of  the  wound. 
This  is  of  especial  importance  where  one  or  more  of  the  carotid 
branches  have  been  ligated.  It  is  never  wise  to  suture  a  wound 
through  the  floor  of  the  mouth  throughout  its  entire  extent ;  to  do  so 
where  a  carotid  branch  has  been  ligated  invites  secondary  hemorrhage. 

2.     Wounds  Involving  the  Bones. 

No  bone  fragments  that  are  not  actually  detached  should  be  re- 
moved. The  remaining  bony  parts  should  be  restored  and  held  in  their 
normal  position  by  appropriate  splints,  and  every  possible  pocket  and 
the  bottom  of  every  detectable  fracture  line  should  be  drained  with 
dependent  drainage.  Bone  fragments  driven  into  the  tissues  about  the 
mouth  may  be  detected  by  digital  palpation  if  the  search  is  made  before 
swelling  occurs.  These  should,  if  possible,  be  removed  or  dependent 
drainage  of  the  space  established.  This  having  been  done,  the  soft 
parts  may  be  repaired  as  already  outlined. 

Wherever  possible  to  ge;.t  at  them,  close  wounds  and  open  cavities 
within  the  first  twelve  hours.  Crile  states  that  if  this  is  done  90  per 
cent  of  all  wounds  heal  per  primaiii,  and  that  the  gas  gangrene  is  elimi- 
nated. First  remove  all  blood  clot  and  foreign  bodies,  control  all  bleed- 
ing, remove  badly  damaged  tissue  with  knife  or  scissors,  and  approxi- 
mate clean  surfaces  with  or  without  an  antiseptic.  With  proper  limi- 
tations, we  see  no  reason  why  this  procedure  should  not  be  carried  out 
with  jaw,  face,  and  neck  injuries;  and  our  preparation  is  based  on  this 
theory. 


BIBLIOGRAPHY. 


This  does  not  pretend  to  be  a  full  bibliography,  but  only  comprises  a  few  titles  of 
the  works  used  in  the  preparation  of  this  volume.  The  best  bibliography  on  this  sub- 
ject is  to  be  found  in  Perthes,  D.  Verletz.  und  Krankh.  d.  Kiefer  ;  while  those  in  von 
Mikulicz,  Krankheiten  des  Mundes,  and  Butlin,  Diseases  of  the  Tongue,  are  carefully 
selected,  but  less  complete. 


CHAPTER  I. 

Examination. 
Gould,  Pierce,  Essentials  of  Surgical  Diagnosis. 

Floor  of  the  Mouth. 

MouLLiN,  Treatise  on  Surgery. 
Treves,  Surgical  Applied  Anatomy. 
PiERSOL,  Human  Anatomy. 

Palate. 

Cunningham,  Human  Anatomy. 

KocHER,  Operative  Surgery. 

Bland-Sutton,  in  Keen's  System  of  Surgery. 

Teeth. 
PuiNZ,  Dental  Materia  Medica. 

Cheeks. 
Bland-Sutton,  in  Piersol's  Human  Anatomy. 


Salivary  Glands. 


Gkay,  Anatomy,  p.  782. 


CHAPTER  II. 

Infections. 

Emery,  Immunity  and  Specific  Therapy. 

Ricketts,  Infection,  Immunity,  and  Serum  Therapy. 

MuiR  and  Ritchie,  Manual  of  Bacteriology. 

Pfeiffer  and  Marx,  Deutsche  medizinische  Wochenschrift,  1898. 

Centralblatt  fiir  Bakteriologie. 

699 


700  BIBLIOGRAPHY. 

CHAPTER  IV. 

Hemorrhage. 

Dawbarn,  Journal  A.  M.  A.,  vol.  xxxvi,  p.  357;  Annals  of  Surgery,  Feb.,  1907. 
WiBTH,  Centralblatt  filr  die  Grenzgehiete  der  Medizin  und  Chirurgie,  1909, 

xii.  No.  7,  pp.  241-288. 
Leaky,  Boston  Medical  and  Surgical  Journal,  1908,  vol.  clix,  p.  73. 
Baum,  Mitteilungen  aus  den  Grenzgebieten  der  Medizin  und  Chirurgie,  1909, 

vol.  XX,  No.  1,  pp.  1-194. 
Morawitz,  Miinchener  medizinische  Wochenschrift,  1907. 
Holt,  Diseases  of  Infancy  and  Childhood. 

Blood  Transfusion. 

Crile,  Journal  A.  M.  A.,  1906,  vol.  xlvii;   Annals  of  Surgery,  1907,  p.  329; 

Journal  A.  M.  A.,  1909,  p.  320. 
Dorrance  and  Ginsburg,  International  Clinics,  vol.  iv,  20th  series. 
Habtwell,  Journal  A.  M.  A.,  1909,  p.  297. 
Lewisohn,  Journal  A.  M.  A.,  1917,  vol.  Ixviii,  p.  826. 
Pepper,  Journal  A.  M.  A.,  1907,  p.  382. 
Rehling  and  Weil,  American  Journal  of  Surgery,  March,  1909. 

Shock. 
MouLLiK,  Treatise  on  Surgery,  Hamilton,  1893,  p.  150. 

Air  Embolism. 

Senn,  Reports  of  Laboratory  Experiments,  Transactions  of  the  American  Sur- 
gical Association,  vol.  iii,  p.  197. 

Hare,  Therapeutic  Gazette,  1889,  vol.  v,  p.  606. 

Blair  and  McGuigan,  A  Suggestion  for  the  Treatment  of  Air  Embolism, 
Annals  of  Surgery,  Oot.,  1910. 


CHAPTER  V. 


Wounds. 

KocHER,  Operative  Surgery. 

Sherman,  W.  O.,  Journal  A,  M.  A..  .July  21,  1917,  p.  185. 


Burns. 

SoLLMAX,  T.,  Journal  A.  M.  A.,  June  16,  1917,  p.  1799. 
Wood,  P.  C,  Keen's  Surgery,  vol.  i,  p.  379. 


BIBLIOGRAPHY.  701 

CHAPTER  VI. 

Fracture  of  the  Teeth. 

WuNSCHEiM,  Frakturen,  Infraktionen,  und  Knickungen  in  Zahnen,  Osterreich- 
ungarische  Vierteljahrsschrift  filr  Zahnheilkunde,  1904,  p.  45. 

Owen,  Odontography,  1840-45,  p.  569. 

Wedl,  Atlas  zur  Pathologie  der  Zdhne,  1893. 

Tomes,  J.  A.,  System  of  Dental  Surgery,  1887,  p.  431. 

Williamson,  An  Interesting  Case  of  Fracture,  Journal  British  Dental  Asso- 
ciation, 1888,  p.  123. 

CHAPTER  VII. 

Fractures  of  the  Upper  Jaw. 
Cryee,  Internal  Anatomy  of  the  Face. 

Treatment. 

LeDentu,  a.,  et  Delbet,  P.,  Noveau  Traite  de  Chirurgie. 

Ombredanne,  Louis,  Maladies  des  Machoires. 

Marshall,  Injuries  and  Surgical  Diseases  of  the  Face,  Mouth,  and  Jaws. 


CHAPTER  VIII. 

Treatment  of  Fractures  of  the  Lower  Jaw. 

Bond,  Thos.  E.,  A  Practical  Treatise  on  Dental  Medicine,  1852. 

EssiG,  N.  S.,  Dental  Casinos,  1917,  vol.  lix,  p.  444. 

Gilmer,  Archives  of  Dentistry,  Sept.,  1887;  Oral  Surgery,  1907,  p.  105,  p.  109. 


CHAPTER  IX. 

Gunshot  Fractures. 

Colyer,  J.  F.,  Journal  Royal  Army  Medical  Corps,  1916,  p.  597. 

Davenport,  W.  S.,  Dental  Cosmos,  1916,  vol.  Iviii,  p.  1135. 

Dolamore,  W.  H.,  British  Journal  of  Surgery,  1915-1916,  vol.  iii,  p.  526. 

Hayes,  G.  B.,  Dental  Cosmos,  1916,  vol.  Iviii,  pp.  249,  389,  511,  658,  758,  1012, 

1143. 
Herpin,  a..  Gazette  hebdomadaire  des  sciences  medicales  de  Bordeaiix,  1917, 

vol.  xxxviii,  p.  43. 
Kazanjian,  V.  H.,  Journal  Allied  Dental  Societies,  1917,  vol.  xii,  p.  29. 
Pont,  M.  A.,  Lyon  medical,  1916,  vol.  cxxv,  p.  294. 
Sauvez,  British  Journal  Dental  Sciences,  1917,  vol.  Ix,  p.  10. 


703  .  BIBLIOGRAPHY. 

CHAPTER  X. 

Kinds  of  Dislocation  of  the  Lower  Jaw. 

LeF^vre,  Journal  HeMomadaire,  1834,  vol.  Hi,  p.  333. 

Robert,  Archives  Generales  de  Medicine,  1845,  vol.  vii,  p.  44. 

Neis,  Luxation  du  Maxillaire  inf.  en  haut  on  dans  la  fosse  Temporale,  These 

de  Paris,  1879,  No.  252. 
Stimson,  Fractures  and  Dislocations. 
Malgaigne,  Atlas,  plate  xvii.  Fig.  1. 

Treatment. 
Gilmer,  Oral  Surgery. 

Chronic  Dislocation. 
Annandale,  Lancet,  1887,  vol.  i,  p.  6411. 


CHAPTER  XI. 

Morphology  of  Congenital  Facial  Clefts. 

Lexer,  in  von  Bergmann's  System  of  Practical  Surgery,  vol.  i. 
Owen,  Harelip  and  Cleft  Palate.  , 

Relation  of  the  Alveolar  Cleft  to  the  Teeth. 

Untersuchen  iiber  des  Zwischenkiefer  in  den  Menschen  in  seiner  Normalen 

und  Abnormalen  Metamorphose,  Stuttgart,  1840. 
Warynski,    Contribution   a   L'etude   du    bee   de   lievre,    simple   et   complex, 

Virchow's  Archiv,  1888. 
Turner,  Sir  William,  Journal  of  Anatomy  and  Physiology,  vol.  xix. 
Kolliker,   Zur  Odontologie   der  Gaumen-spalte,   Centralblatt  filr  Chirurgie, 

1890,  vol.  XV. 

Theories  of  Failure  of  Cleft  Closure. 

Fein,  Uber  die  Ursachen  des  Wolfsrachen,  Wiener  klinische  Wochenschrift, 

1899,  vol.  X. 
Tandler,  Zur  Entwicklungs  Geschichte,  Wiener  klinische  Wochenschrift,  1899, 

vol.  X. 
Friedrich,  Archiv  fiir  klinische  Chirurgie,  Bd.  68,  heft  2,  p.  199. 
Fronhofer,  H.,  Die  Enstehung  der  Lippen-kiefer  und  Gaumen-spalten  in  folge 

Amniotischen  Adhesionen. 
Ziegler,  Allgemeine  Pathologie,  1895. 
DRtHTT,  Modern  Surgery. 

Vander,  a.,  Rebman's  Handbook  of  Medical  Sciences,  p.  179. 
Czapski,   Binokulares  Korneal   Mikroskop,  Archiv  fiir  Ophthalmologic,  vol. 

xlv,  pp.  222-235. 


BIBLIOGRAPHY.  703 

LuEDDE,  Improved  Illumination  for  the  Ziess  Binocular  Corneal  Microscope — 
Used  in  the  Study  of  the  Episcleral  Vessels  and  their  Circulation,  Archives 
of  Ophthalmology,  vol.  xl,  No.  4,  p.  19. 

Graves,  The  Scaphoid  Scapula,  Medical  Record,  May,  1910;  The  Clinical  Rec- 
ognition of  the  Scaphoid  Type  of  Scapula  and  Some  of  Its  Correlations, 
Journal  A.  M.  A.,  July  2,  1910. 


CHAPTER  XII. 

Anatomical  Considerations  of  Congenital  Palate  Clefts. 

Spalteholz,  Hand  Atlas  of  Anatomy. 

Merkel,  Handbuch  der  Topographischen  Anatomie,  vol.  i,  p.  401. 

Flaps  made  from  other  than  Palate  Tissues. 
Marshall,  Injuries  and  Surgical  Diseases  of  the  Face,  Mouth,  and  Jaws. 


CHAPTER  XIV. 

CONGENITAL  PALATE  AND  LIP  CLEFTS. 

Brophy  Operation. 

Heitmitller,  Correspondmzhlatt  fiir  Ziihnartze,  vol.  xxxiii,  No.  1. 
Owen,  Edmund,  Burghard's  Operative  Surgery,  vol.  ii. 

Lane  Operation. 

Lane,  Cleft  Palate  and  Harelip. 

Mortality. 
RoRERTR,  Surgery  of  Deformities  of  the  Face. 

CHAPTER  XV. 
CONGENITAL  PALATE  CLEFTS. 
Flap  Sliding  Operation. 
Owen,  Keen's  Surgery,  vol.  iii,  p.  627. 

CHAPTER  XVIII. 

OBTURATORS  AND  SPEECH  TRAINING. 

Physiological  Action  of  the  Muscle  Concerned. 

KiNGSLEY,  Oral  Deformities. 

Warnekros.  Ashr's  Qiiarferli/.  April,  1909. 


704  BIBLIOGRAPHY. 

Obturators  and  Artificial  Vela. 

War>-ekros,  Verhandlungen  der  Deutschen  Odontologeschen  Gesellschaft,  vol. 
vil,  Schaff' s  Handbuch. 

Speech  Training. 
BiGELow,  Voice  Training  after  Operation  for  Cleft  Palate. 


CHAPTER  XIX. 
Restoration  of  the  Lower  Lip. 

Stewart,  Clark,  The  Radical  Treatment  of  Epithelioma  of  the  Lip,  Journal 

A.  M.  A.,  vol.  liv,  No.  3. 
EsMAECH  AND  KowALZiG,  Surgical  Technic. 

Soft  Tissues. 

Babcock,  W.  W.,  Journal  of  the  A.  M.  A.,  1915,  vol.  Ixiv,  p.  203. 

Bryan,  W.  A.,  Dental  Summary.  1916,  vol.  xxxvi,  p.  157. 

Cole,  P.  P.,  Lancet,  London,  1917,  vol.  i,  p.  415. 

Cruise,  R.,  Hastings,  S.,  and  Wood.  D.,  Journal  Royal  Army  Medical  Corps, 

1916,  vol.  xxvi,  p.  324. 
EssER,  J.  F.,  Annals  of  Surgery,  1917,  vol.  Ixv,  p.  297;   Surgery,  Gynecology, 

and  Obstetrics,  1917,  vol.  xxiv,  p.  737. 
HoRSLEY,  J.  S.,  Journal  A.  M.  A.,  1916,  vol.  Ixvi,  p.  411. 
VoN  Hacker,  Beitriige  zur  klinischen  Chirurgie,  1916,  vol.  xcviii,  p.  289. 

Bone  and  Cartilage. 
Cavalie,  Bulletin  et  mcmoires  cle  la  Socictc  de  Med.  et  chirurgie  de  Bor- 

deaux,  pp.  93-96. 
Imuert,  L.,  and  Real,  P.,  Marseille  Medical,  1916,  vol.  liil,  p.  193. 
McWilliams,  C.  a.,  Annals  of  Surgery,  1917,  vol.  Ixv,  p.  283. 
MoRESTiN,  H.,  Bulletin  et  mcmoires  de  la  Socictc  de  chirurgie  de  Paris,  1915, 

vol.  xli,  pp.  1994,  2418,  2459. 

Acquired  Palate  Defects. 

Imbert,  L.,  AND  L'Heureux,  C,  Marseille  Medical,  1916,  vol.  liii,  p.  81. 
MoRESTiN,  H.,  Bulletin  et  mcmoires  de  la  Socicte  de  chirurgie  de  Paris,  1916, 
vol.  xlii,  p.  1711. 

CHAPTER  XX. 

Occlusion  and  Malocclusion. 
LiscHEB,  Orthodontics. 

CHAPTER  XXL 
Protrusion  of  the  Lower  Jaw. 
Babcock,  W.  Wayne,  Items  of  Interest,  June,  1910. 


BIBLIOGRAPHY.  705 

CHAPTER  XXV. 

Infections  and  Inflammations  of  the  Mouth. 

BuTLiN,  Diseases  of  the  Tongue. 

Bruck,  Diseases  of  the  Nose,  Mouth,  Throat,  and  Larynx. 

Pfaundlee  and  Schlossmann,  Diseases  of  Children. 

Specific  Infections. 

Campbell,  A.  R.,  and  Dyas.  A.  D.,  Journal  A.  M.  A.,  1917,  vol.  Ixviil,  p.  1596. 

Caeb,  Practice  of  Medicine,  p.  762. 

Bristow,  a.  T.,  Annals  of  Surgery,  Oct.,  1911. 

SiEGEL,  Deutsche  medizinische  WocJienschrift,  1891,  vol.  xvii,  p.  1328;   1894. 

vol.  XX,  pp.  420-426. 
EiCHMEYER,  W.,  Ergebnisse  der  Allgemeinen  Pathologie  Lehrbuch. 

CHAPTER  XXVI. 

Necrosis. 
Detuek,  Archives  Generales  de  Chirurgie,  Nov.,  1908. 

CHAPTER  XXVII. 

Treatment  of  Necrosis. 
CuSHNEY,  Pharmacology  and  Therapeutics  (potassium  iodid). 

Chronic  Bone  Abscess. 

MosETiG-MooRHOF,  Wiener  klinische  Woche?ischrift,  1906,  No.  44. 
Beck,  Bismuth  Paste  in  Chronic  Suppuration. 
David  and  Kaufmann,  Journal  A.  M.  A.,  1909,  vol.  lii,  p.  1055. 
Mayohofer,    Osterreich-ungarische    Yierteljahrsschrift    filr    Zdhnheilkunde, 
1905,  No.  2;  1906,  No.  3;  1907,  No.  L 

CHAPTER  XXVIII. 
Chronic  Cellulitis. 
PiCHTER,  Milnchener  medizinische  Wochenschrift,  1904,  p.  35. 

CHAPTER  XXIX. 

Antral  Infection. 

Ballekger,  Ear,  Nose,  and  Throat. 

MiKXJLicz,  Langenieck's  Archiv  filr  klinische  Chirurgie,  vol.  xxxiv. 

Sludeb,  Laryngoscope,  December,  1909. 


706  BIBLIOGRAPHY. 

CHAPTER  XXX. 

Hypertrophy  of  the  Gums. 
Crter,  Internal  Anatomy  of  the  Face. 

Odontoma. 
Gilmer,  Oral  Surgery. 

Sarcoma  of  the  Jaws. 

ScuDDER,  Tumors  of  the  Jaws. 

CoLEY,  Injury  as  a  Causative  Factor  in  Carcinoma. 

Multilocular  Cystic  Tumors  of  the  Jaws. 
Bland-Sutton,  Keen's  Surgery,  vol.  i,  p.  784. 

Carcinoma  of  the  Jaws. 

Blair,  V.  P.,  International  Abstract  of  Surgery,  1916. 

Ivy.  R.  H.,  Journal  A.  M.  A.,  1915,  vol.  Ixiv,  p.  40. 

Schlatter,  Von  Bergmann's  System  of  Practical  Surgery,  vol,  i,  p.  708. 

CHAPTER  XXXI. 

Mortality  of  Total  Resection  of  the  Maxilla. 
Schlatter,  Von  Bergmann's  System  of  Practical  Surgery,  vol.  i,  p.  726. 

Prevention  of  Deformity. 

Gilmer,  Conservative  Surgery  for  the  Treatment  of  Diseases  of  the  Mandible, 

Journal  A.  M.  A.,  Aug.  7,  1909. 
Maqnuson,  University  of  Pennsylvania  Medical  Bulletin,  1908,  vol.  xxi,  p.  103. 

CHAPTER  XXXIII. 

Cancer  of  the  Lip. 
Lexer,  Von  Bergmann's  System  of  Practical  Surgery,  vol.  1. 

CHAPTER  XXXIV. 

Ranula. 

Baker,  St.  Bartholomew's  Hospital  Report,  1871,  vol.  vii,  p.  134. 
Morestin,  Gazette  d'Hopitaux,  1897,  vol.  Ixx,  p.  529. 

Mo.Noi),  Bulletin  et  memoires  de  la  Hocicte  de  chirurgie  de  Paris,  1881,  vol. 
vii,  p.  365. 


BIBLIOGRAPHY.  707 

CHAPTER  XXXV. 

Secondary  Affections  o£  the  Salivary  Glands. 
KuTTNER,  Von  Bergmann's  System  of  Practical  Surgery,  vol.  i. 

Foreign  Bodies  in  the  Ducts  and  Glands. 
PuzEY,  Lancet,  1884,  vol.  i,  p.  424. 

Benign  Tumors. 

Bland-Sutton,  Keen's  Surgery,  vol.  i,  p.  752. 

Hayes,  Medical  Neics,  Philadelphia,  1893,  vol.  Ixii,  p.  60. 

BuTLiN,  Diseases  of  the  Tongue. 

CHAPTER  XXXVI. 

Congenital  Deformities  of  the  Tongue, 

Makuen,  International  Clinics,  1897,  7th  series,  vol.  i,  p.  319. 

DuPLONG,  Bulletins  et  mvmoires  cle  la  Socictc  cle  Chirurgie  cle  Paris,  1883, 

n.  s.,  T.  ix,  p.  457. 
Petit,  Memoires  Acad.  Roy.  des  Sciences,  1742,  p.  247. 
JussiEU,  Hist,  de  L'Acad.  des  Sciences,  1718. 

Dyspeptic  Tongue. 

Butlin,  Diseases  of  the  Tongue. 

Chronic  Superficial  Glossitis. 

Butlin,  Trans.  Path.  Med.  Chir.  Sac,  1878,  vol.  Ixi,  p.  51. 

Sangster,  Trans.  Path.  Sac,  1882,  vol.  xxxiii,  p.  103. 

LissAUER,  Deutsche  medizinische  Wochenschrift,  1899,  vol.  xxv,  p.  12. 

HuLKE,  Transactions  Clinical  Society,  London,  1869,  vol.  ii,  p.  1. 

Ciaglinski  and  Hewelke,  Zeitschrift  fiir  klinische  Medizin,  1893,  vol.  xxii, 

p.  626. 
Lediard,  Transactions  Pathological  Society,  1886,  vol.  xxxvii,  p.  222. 

Syphilis  of  the  Tongue. 

Fournier,  Des  Glossites  Tertiares,  Paris,  1877. 

Morris,  Sir  Malcolm,  British  Medical  Journal,  March  30,  1912,  p.  712. 

CHAPTER  XXXVIL 

Lymphangiomatous  Macroglossia. 
Butlin,  Diseases  of  the  Tongue. 

Simple  Muscular  Macroglossia. 
Zeisler,  New  York  Medical  Record,  1885,  vol.  xli,  p.  253. 


708  BIBLIOGRAPHY. 

Keloid. 
Sedgwick,  Transactions  Pathological  Society,  1861,  vol.  xil,  p.  234. 

Thyroglossal  Cysts  and  Tumors. 

Beenays,  St.  Louis  Medical  and  Surgical  Journal,  1888,  vol.  iv,  p.  201. 

Von  Chamisso  de  Boncotjrt,  Beitrage  zur  Jclinischen  Chirurgie,  1897,  vol.  xix, 

p.  281. 
Seldowitsch,  New  York  Medical  Journal,  1897,  vol.  Ixv,  p.  281. 
Reintjes,  Internationales  Centralblatt  filr  Laryngologie,  1899,  xv,  174. 
Streckheisen,  ArcTiiv  filr  pathologische  Anatomic,  1886,  cili,  131-215. 


CHAPTER  XXXVIII. 

CANCER  OP  THE  TONGUE. 

Etiology  and  Predisposition. 
Cheatle,  British  Medical  Journal,  Feb.  22,  1908. 

Early  Types  of  Cancer. 

BuTLiN,  British  Medical  Journal,  1909,  p.  462;   Jan.  2,  1909;   Feb.  14,  1903; 
May  26,  1906. 

Mid-Period  of  Cancer  of  the  Tongue. 

BuTLiN,  British  Medical  Journal,  Feb.  11,  1905;  May  26,  1906. 
Mikulicz  und  Kummel,  Krankheiten  des  Mundes. 

Diagnosis. 

Head,  Eye,  Ear,  Nose,  and  Throat,  Practical  Medicine  Series  of  Year  Books, 

1903. 
BuET,  H.,  Journal  of  Laryngology,  Rhinology  and  Otology,  Jan.,  1903. 

Prognosis. 

BuTLiN,  British  Medical  Journal,  Jan.  2,  1909;  Feb.  20,  1909. 
DoLLiNGER,  British  Medical  Journal,  May  30,  1903. 

Treatment. 

LoisoN,  Von  Bergmann's  System  of  Practical  Surgery,  vol.  i,  p.  874. 

BuTLiN,  British  Medical  Journal,  Jan.  2,  1909. 

KocHER,  Operative  Surgery. 

Maitland,  Australian  Medical  Gazette,  Oct.  20,  1906. 

Andrews,  Keen's  Surgery,  vol.  ill,  p.  332. 


BIBLIOGRAPHY.  709 

CHAPTER  XXXIX. 

Secondary  Carcinoma  o£  the  Cervical  Lymphatics. 
Maitland,  Australian  Medical  Gazette,  Oct.  20,  1906. 

Injuries  of  the  Oral  Pharynx. 
Jacobson,  Operation  of  Surgery. 

Acute  Infections  of  the  Pharynx. 
Pitt,  St.  Thomas  Hospital  Reports,  vol.  xil,  p.  131. 

Adhesions  of  the  Velum. 

Roe,  John  A.,  Journal  A.  M.  A.,  vol.  liv.  No.  3,  p.  185. 
KtJMMEL,  Von  Bergmann's  System  of  Practical  Surgery,  vol.  i. 
Nichols,  A.,  Method  of  Correcting  Adhesions  Between  the  Soft  Palate  and  the 
Pharyngeal  Wall,  New  York  Medical  Journal,  1890,  vol.  xi,  p.  219. 

CHAPTER  XLI. 

Palate  Adenoma. 

KiJMMEL,  Von  Bergmann's  System  of  Practical  Surgery,  vol.  i. 

Pharyngotomy. 
Jacobson,  Operations  of  Surgery,  p.  378. 

CHAPTER  XLII. 

Ligation  and  Temporary  Construction  of  the  Arteries. 
KocHER,  Operative  Surgery. 

External  Carotid  Artery. 

Cunningham,  Textbook  of  Anatomy. 

CHAPTER  XLIV. 

Fifth  Cranial  Nerve. 
PiEKSOL,  Human  Anatomy. 

Sphenopalatine  Neuralgia. 

Sltjder,  The  Role  of  the  Sphenopalatine  or  Meckel's  Ganglion  in  Nasal  Head- 
aches, New  York  Medical  Journal,  May  23,  1908;  The  Anatomical  and 
Clinical  Relations  of  the  Sphenopalatine  or  Meckel's  Ganglion  to  the  Nose 


710  BIBLIOGRAPHY. 

and  Its  Accessory  Sinuses,  New  York  Medical  Journal,  Aug.  14,  1909; 
Further  Clinical  Observations  on  the  Sphenopalatine  Ganglion-Motor, 
Sensory,  and  Gustatory,  New  York  Bledical  Journal,  April  23,  1910;  A 
Phenol  (Carbolic  Acid)  Injection  Treatment  for  Sphenopalatine  Ganglion 
Neuralgia,  Journal  A.  M.  A.,  Dec.  30,  1911,  p.  2137. 

Weiner,  Otto,  Berliner  kJinische  Wochenschrift,  vol.  xliv.  No.  10,  p.  429, 
March  7,  1910. 

Patrick,  Journal  A.  M.  A.,  vol.  xlix,  pp.  1567,  1987. 

Keen,  Surgery,  vol.  v. 

Crow  and  Gushing,  Johns  Hopkins  Bulletins,  1909,  p.  102. 


CHAPTER  XLV. 
Local  Anesthesia. 

Prinz,   Modern   Methods   of  Producing  Local   Anesthesia,   Dental   Summary, 
1912,  Feb.,  March,  and  April. 


INDEX. 


Abrasion  of  the  teeth,  mechanical,  83 
symptoms  of,  83 
treatment  of,  83 
Abscess,  absorption,  386 
acute,  375 
alveolar,  375 

treatment  of,  392 
blind,  378 
chronic  bone,  treatment  of  399 

by  obliteration  of  cavity  with 

bone  plombe,  401 
by  obliteration  of  cavity  with 

living  tissue,  403 
with  Beck's  bismuth  paste,  401 
definition  of,  34 
of  gums,  18 
of  tongue,  417 
peritonsillar,  612 

treatment  of,  612 
retropharyngeal,  613 

treatment  of,  614 
tonsillar,  611 

treatment  of,  612 
Absorption  abscess,  386 
Acetone,  Legal's  test  for,  64 
Acetonuria,  63 
Actinomycosis  of  bone,  388 
of  the  mouth,  369 
of  the  salivary  glands,  500 
Acute  adenitis,  409 
treatment  of,  411 
catarrhal  stomatitis,  349 
cellulitis,  409 

treatment  of,  412 
infections  of  the  pharynx,  611 
pharyngitis,  611 
tonsillitis,  611 
ulcerous  gingivitis,  379 
Adenoma  of  the  salivary  glands,  516 
palate,  621 

treatment  of,  621 
Adenitis,  acute,  409 
treatment  of,  411 
chronic,  411 

treatment  of,  415 
tuberculous,  593 
diagnosis  of,  594 
radical  operation  for,  597 

results  of,  602 
symptoms  and  course  of,  593 
treatment  of,  594 


Adhesions  of  the  velum,  fauces,  and 
pharyngeal  wall,  615 
prognosis  of,  618 
treatment  of,  616 
Adrenalin  in  local  anesthesia,  676 
After-treatment  of  clefts  of  lips  and 
alveolar  process,  240 
of  congenital  palate  clefts,  195,  215 
of  operations  on  deformities  of  the 

jaws,  312 
of  operations   on    impacted    teeth, 

347 
of  operations  on  the  tongue,  390 
of  resections  of  the  maxilla,  459 
of  transplantation  of  skin-  or  mu- 
cus-covered flaps,  278 
Air  embolism,  59 

experiments  in,  59-61 
Albrecht,  theory  of  relation  of  alveo- 
lar cleft  to  the  teeth,  162 
Alveolar  abscess,  375 
acute,  375 
chronic,  376 

treatment  of,  392 
cleft,  relation  to  the  teeth,  160 
Albrecht's  theory,  162 
Ferguson's  theory,  161 
Kolliker's  theory,  162 
Warnekros'  theory,  161 
clefts,  correction  of,  in  infants,  228 
double,  corrections  of  at  later  pe- 
riods, 229 
single,  corrections  of  at  later  pe- 
riods, 229 
process   and    lip,   congenital   clefts 
of,  after-treatment  of,  240 
operative    correction    for,    227- 

241 
results  of,  241 
fracture  of  the,  85 
treatment  of,  85 
resection  of  the  inferior,  461 
of  the  palate  and,  455 
of  the  superior,  454 
Anastomosis,    facial-accessory    nerve, 
639 
facial-hypoglossal  nerve,  639 
Anatomical  considerations, 

of  congenital  palate  clefts,  172 
Anatomy,  2-27 

of  Bochdalek's  glands,  6 

of  fauces,  14 

of  floor  of  the  mouth,  4 


711 


712 


INDEX. 


Anatomy — cont'd 
of  glands  of  Nuhn  and  Blandin,  5 
of  gums,  17 
of  incisive  glands,  5 
of  jaws,  22 
of  lips,  20 
of  lymph  nodes,  26 
of  maxillary  antrum,  23,  418 
of  mouth  cavity,  2 
of  muscles  of  mastication,  24 
of  palate,  12 
of  parotid  gland,  24 
of  pharynx,  14,  606 
of  salivary  glands,  24 
of  sublingual  glands,  24 
of  submaxillary  glands,  25 
of  teeth,  15 

of  temporomandibular  joint,  21 
of  tongue,  12 
of  vestibule  of  mouth,  19 
Anemia,  means  of  producing,  675 
Anesthesia  in  operation  for  removal 
of  the  tongue,  581 
general,  691-696 
by  insufflation,  693 
chloroform  in,  696 
ether  in, 696 
infiltration,  695 
intratracheal,  693 
nitrous  oxid  in, 695 
local,  675-690 

absorption  of  poisonous  drugs  in, 

677 
adrenalin  in,  676 

anesthetization  of  the  pulp  in,  687 
cocain  in,  677 
ethyl  chlorid  in, 676 
for  anesthetizing  the  skin.  689 
for  operations   about   the  mouth, 

689 
hypodermic    armamentarium    in, 

681 
intraosseous  injection  in,  686 
means  of  producing,  675 
novocain  in,  677,  679 
peridental  injection  in,  685 
perineurial  injection  in,  686 
preparation  of  solution  in,  678 
subperiosteal  injection  in,  684 
technique  of  injection,  683 
Aneurysm  of  the  tongue,  452 
Angina,  Ludwig's,  410 
of  Plant,  361 
Vincent's,  361 
Angioma  of  the  lips,  471 

of  the  tongue,  cavernous,  540 
diagnosis  of,  541 
treatment  of,  541 
Angle  fracture  bands,  100 

splint.  Brown's  modification  of,  308 
Ankyloglossia,  524 


Ankylosis,  limitation  of  jaws  due  to 
scar  bands  or,  317 
of  the  jaw,  operations  for,  322 
Anthrax,  358 
Antitoxin,  37 
tetanus,  72 
Antral  infection,  418 

objective  symptoms  of,  420 
subjective  symptoms  of,  419 
treatment  of  a,cute,  421 
treatment  of  chronic,  422 

Caldwell-Luc  operation  in,  423 
Canfield-Ballenger   operation 

in, 425 
Denker  operation  in,  423 
Kiister  operation  in,  423 
x-ray  in,  420 
Antrum,  cysts  of  the,  425 
treatment  of,  426 
maxillary,  anatomy  of,  23,  418 
tumors  of  the,  426 
treatment  of,  426 
Aphthae,  352 

Bednar's,  353 
Aphthous  stomatitis,  352 
Approximation    of    the    maxillae    in 
congenital   palate  clefts,   221 
Arsenic  poisoning,  388 
Arterial  bleeding,  48 

Horsley's  formula  for,  48 
Arteries,  constriction  of  the,  629 
common  carotid,  633 
coronary, 630 
external  carotid,  631 
facial,  630 
lingual,  630 
temporal,  630 
ligation  of  the,  52,  629 
common  carotid,  633 
coronary, 630 
external  carotid, '.CI 
facial,  630 
lingual,  630 
temporal,  630 
Articulator,  Guilford's,  111 
Atresia  of  the  posterior   n^res,   607 
Atrophy  of  bone,  390 
Atropin,  use  of,  after  proctoclysis,  54 
Atypical  deformities  of  the  jaws,  311 
Autogenous  vaccines,  method  of  pre- 
paring and  administering,  37 
Avulsion  of  the  frontal  nerve,  666 
of  the  nasal  nerve, 666 
of  the  teeth,  84 
treatment  of,  84 


B 


Babcock,  operation  for  protrusion  of 

the  lower  jaw,  309 
Baby's    mouth,    method    of    washing 

349 


INDEX. 


713 


Bacillus  fusiformis,  355,  361,  362 
gas,  73 

Klebs-Loffler,  358 
leprae,  359 
mallei,  358 
of  Frisch,  360 
of  Siegel,  359 
Bacteria,  cultures  of,  38 
dead,  method  of  using,  38 

reaction  from  injection  of,  39 
of  suppuration,  33 
Wright's    method    of    determining 
number  of,  38 
Bandaging  gunshot   fractures  of  the 

jaw,  145 
Bartlett  elevator,  204 
Barton  bandage,  modified,  144 
Beck's  bismuth  paste  in  chronic  bone 

abscess,  401 
Bednar's  aphthae,  353 
Bell's  palsy,  636 
Benign  tumors,  40 

of  the  pharynx,  620 
Bier's  hyperemia   for  inflammations, 

36 
Bigelow,  speech  training,  246 
Bismuth    paste.    Beck's,    in    chronic 
bone  abscess,  401 
poisoning,  388 
Bite,  open,  285,  310 

correction  by  traction  of,  310 

by  surgical  operation,  310 
operation  for,  310 
fixation  in,  310 
Black  tongue,  532 
Bleeding,  arterial,  48 

Horsley's  formula  for,  48 
in  extraction  of  teeth,  control  of,  50 
veins,  49 
Blind  abscess,  378 
Blood  pressure,  lowering  of,  51 

sequestration  of,  for  prevention  of 

hemorrhage,  46 
supply  of  transplanted  flap,  257 
transfusion,  55 

for  prevention  of  hemorrhage,  48 
vessels,  tumors  of,  539 
Bochdalek's  glands,  anatomy  of,  6 
Bone   abscess,   chronic   treatment   of, 
399 
by  obliteration  of  cavity  with 

bone  plombe,  401 
by  obliteration  of  cavity  with 

living  tissue,  403 
with  Beck's  bismuth  paste,  401 
actinomycosis  of,  388 
atrophy  of,  390 
grafts,  294,  264 

combined  pedicled  bone  and  soft 

tissue,  269 
fixation  of  maxilla,  272 
free,  264 
preparation  of  wound  for  recep- 


Bone  grafts — confd 
tion  of,  266 
repair    of    defects    in    the    lower 

jaw,  266 
repair    of    defects    in    the    upper 

jaw,  265 
semipedicled,  267 
transplantation,  273 
hypertrophy  of,  390 
inflammation  of  the,  383 
or  cartilage,  transplantation  of,  for 

obliquity  of  the  chin,  298 
plombe  in  chronic  bone  abscess,  401 
specific  infections  of,  388 

treatment  of,  407 
syphilis  of,  388 

treatment  of,  408 

tuberculosis  of,  389 

treatment  of,  407 

tumors  of  the,  391 

Branchial  fistula,  608 

diagnosis  of,  609 

treatment  of,  609 

Brophy  elevator,  204 

operation  for  cleft  palate,  184 
oral  speculum,  201 
Brown's    modification    of    Hammond 

splint,  308 
Burns,  77 

from  chemical  caustics,  78 
shock  in,  77 
treatment  of,  78 
x-ray,  78 
Burow-Stewart   operation    for   restor- 
ing the  lower  lip,  262 
Butlin,  ointment  for  herpes,  351 


Calcium    lactate    for    prevention    of 

hemorrhage,  47 
Calculi  in  glands  of  Nuhn  and  Blan- 
din, 502 
salivary,  502 

treatment  of,  504 
Caldwell-Luc    operation    for    chronic 

antral  infection,  423 
Cancer  of  the  lip,  474-483 

of  the  tongue,  551-592 
Cancrum  oris,  355 

treatment  of,  356 
Canfield-Ballenger       operation        for 
chronic  antral   infection,  425 
Capillary  nevi  of  the  tongue,  539 
Carbuncle  of  the  lips,  470 
Carcinoma,  41,  440 
classification  of,  41 
infection    of   neck   glands   delayed, 

449 
of  the  cervical  lymphatics,  603 
results  of  operation  on,  605 
treatment  of,  603 
of  the  floor  of  the  mouth,  491 


"14 


INDEX. 


Carcinoma — cont'd 
of  the  jaws,  medullary,  441 
prognosis  of,  442 
treatment  of,  442 
local  operation,  447 
radical  operation,  446 
use  of  local  irritants,  449 
of  the  lip,  474-483 
diagnosis  of,  474 

excision  of  growths  and  ulcers  of 
doubtful  character  for,  477 
of  indolent,  478 
of  indurating,  478 
operation  for  early  indurated,  478 
where    repair    is    to    be    made 
with  flaps  from  the  neck,  482 
prognosis  of,  483 
treatment  of,  475 
of  the  lower  jaw,  441 
of  the  mouth,  443 
of  the  pharynx, 624 
of  the  salivary  glands,  516 
of  the  tongue,  551-592 
age  in, 552 
chronicity  of,  555 
continuous  growth  of,  556 
death  from,  563 
diagnosis  of,  564 
differential,  565 
microscopical,  567 
differentiation   between    operable 

and  inoperable,  568 
early   clinical   characteristics   of, 

555 
early  diagnosis  of,  553 
early  types  of,  554 
etiology  of,  551 
final  stage  of,  563 
induration  of,  556 
microscopical  appearance  of,  557 
mid-period  of,  558 
clinical  types  of,  562 
general  symptoms  of,  563 
growth  of,  558 
hemorrhage  of,  559 
lymphatic  infection  in,  559 
pain  of,  558 
salivation  in,  559 
ulceration  of,  558 
operation  on,  571 
character  of,  573 
excision    of    tongue    or    laryn- 

gotomy  first  in,  579 
extent  of,  571 
questions  con(;erning,  572 
removal  of  lymphatics  in,  574 
removal  of  lymph  nodes  in,  574 
time  of,  572 
pain  of,  556 
position  of,  551 
predisposition  to,  551 
prognosis  of,  569 
results  of  operation  on,  570 


Carcinoma  of  tongue — cont'd 
treatment  of,  570 
ulceration  in,  556 
of  the  upper  jaw,  440,  441 
Caries  of  teeth,  17 

Carotid  artery,  common,  constriction 
of,  633 
ligation  of,  633 
external,  constriction  of,  631 
ligation  of,  631 
Carrel-Dakin  treatment,  70,  73 
Cartilage  grafts,  249 

transplant     in     correction     of     de- 
pressed bridge,  331 
Cartilaginous  tumors  of  tongue,  543 
Caustics,  chemical  burns  from,  78 
Cavernous  angioma  of  the  tongue,  540 
diagnosis  of,  541 
treatment  of,  541 
Cellulitis,  30 
acute,  409 

treatment  of,  412 
chronic,  411 

treatment  of,  416 
Cementoma,  432 
Cementum,  372 

Cervical    lymphatics,    malignant    dis- 
eases of  the,  593 
radical  operation  for  tuberculous 
infection  of  the,  597 
results  of,  602 
secondary  carcinoma  of  the,  603 
results  of  operation,  605 
treatment  of,  603 
tuberculosis  of  the,  593 
Chancre  of  the  mouth,  366 

of  the  tongue,  534 
Cheek  and  the  mouth,  closure  of  de- 
fects at  the  angle  of  the,  257 
Cheek  flaps,  252 

Chemical  caustics,  burns  due  to,  78 
Chicken-pox,  357 
Children,  examination  of.  1 
Chin,  obliquity  of  the,  296 
paraffin  injection  for,  297 
transplantation  of  bone  or  tissue 
for,  298 
Chloroform  in  general  anesthesia,  691 
Chondroma,  430 
Chronic  abscess,  378 
adenitis,  411 

treatment  of,  415 
alveolar  abscess,  376 

treatment  of,  394 
bone  abscess,  treatment  of,  399 

by  obliteration  of  cavity  with 

bone  plombe,  401 
by  obliteration  of  cavity  with 
living  tissue,  403 
with  Beck's  bismuth  paste,  401 
cellulitis,  411 
dislocations,  152 
treatment  of,  416 


INDEX. 


715 


Chronic — cont'd 
inflammation      of      tlie      salivary- 
glands,  498 
pericementitis,  381 
treatment  of,  405 
stomatitis,  350 
superficial  glossitis,  528 
ulcerative  stomatitis,  360 
Cleft  closure,  theories  of  failure   of, 
164 
heredity,  164 
infection,  168 
injury,  168 
malnutrition,  167 
maternal  impressions,  167 
mechanical  cause,  165 
supernumerary  teeth,  166 
tumors,  166 
palate  speech, 245 
Clefts,  alveolar,  correction  of,  in  in- 
fants, 228 
congenital  facial,  153-169 
clinical  types  of,  163 
Merkel's  plan  of,  154 
morphology  of,  153 
theories  of,  164 
types  of,  155 
lip'  and    alveolar    process,    after- 
treatment  of,  240 
correction  of,  227-241 
results  of,  241 
palate,  170-226 

advantages  of  very  early  oper- 
ation for,  180 
after-treatment  of,  195,  215 
anatomical    considerations    of, 

170 
approximation  of  the  maxillae 

in, 221 
Brophy  operation  for,  184 
choice  of  operation  for,  195 
consideration    of   various   ages 

for  operation  for,  179 
Davies-Colley  operation  for,  193 
double,  172 

flap  sliding  operation  for,  205 
instruments  and  materials  for, 

200 
Kiister  operation  for,  217 
Lane  operation  for,  192 
Langenbeck  operation  for,  207 
mortality  in,  296 
mortality  in  operations  for,  197 
non-union  in,  215 
operations  in  early  infancy  for, 

182-197 
operation      for      extraordinary 

cases  of,  217-226 
plastic  operations  in  ordinary 
cases     after     early     infancy, 
198-216 
position  and  light  in  operation 
on, 199 


Clefts,  palate — cont'd 

postoperative    hemorrhage    in, 

215 
preferable  age  at  which  to  op- 
erate, 179-181 
preparation  for  operation,  182 

199 
principles  of  repair  by  plastic 

flaps,  170-178 
reoperation  in, 216 
repair  by  flaps  from  other  than 

palate  tissues,  176,  223 
repair  by  flaps  from  palate  tis- 
sues, 173 
results  in,  216 
retention  devices  for,  213 
single,  172 

two-step  operation  for,  217 
double  alveolar,  correction  of,  229 
single  alveolar,  correction  of,  229 
Closed  wounds,  68 
Closure  of  the  jaws,  hysterical,  314 
Clotting,  delayed,  treatment  of,  50 
Cocain  as  local  anesthetic,  677 
Cold,  application  of,  for  hemorrhage, 

50 
Coley's  fluid  for  retromaxillary  fibro- 
ma, 452 
for  sarcoma,  438 
Complications   in   gunshot    fractures, 

139 
Composite  odontoma,  433 
Compound  follicular  odontoma,  432 
Congenital  clefts  of  the  lip  and  alve- 
olar process,  227-241 
after-treatment  of,  240 
operative  correction,  227 
results  of,  241 
deformities  of  the  tongue,  524 
facial  clefts,  153-169 

clinical  types  of,  163 
Merkel's  plan  of,  154 
morphology  of,  153 
theories  of,  164 
types  of,  155 
lip  pits,  169 

malformations    of   the  pharynx,  606 
palate  clefts,  170-226 

advantages  of  very  early  oper- 
ations for,  180 
after-treatment  of,  195,  215 
anatomical    considerations    of, 

170 
approximation  of  the  maxillae 

in, 221 
Brophy  operation  for,  184 
choice  of  operation  for,  195 
consideration    of  various   ages 

for  operation  for,  179 
Davies-Colley      operation      for, 

193 
double,  172 
flap-sliding  operation  for,  205 


716 


INDEX. 


Congenital  palate  clefts — cont'd 

instruments  and  materials  for, 

200 
Kiister  operation  for,  217 
Lane  operation  for,  192 
Langenbeck  operation  for,  207 
mortality  in,  216 
mortality  in  operation  for,  197 
non-union  in,  215 
operations     for     extraordinary 

cases  of,  217-226 
operations  in  early  infancy  for, 

182-197 
plastic  operations  in  ordinary 
cases     after     early     infancy, 
198-216 
position  and  light  in  operation 

on, 199  ■ 
postoperative    hemorrhage    in, 

215 
preferable  age  at  which  to  op- 
erate, 179-181 
preparation  for  operation,  182, 

199 
principles  of  repair  by  plastic 

flaps,  170-178 
reoperations  in, 216 
repair  by  flaps  from  other  than 

palate  tissues,  176,  223 
repair  by  flaps  from  palate  tis- 
sues, 173 
results  in,  216 
retention  devices  for,  213 
single,  172 

two-step  operation  for,  217 
Constriction  of  the  arteries,  629 
common  carotid,  633 
coronary,  630 
external  carotid,  631 
facial,  630 
lingual,  630 
temporal,  630 
Contused  wounds,  65 
Coronary  artery,  constriction  of,  630 
Correction    of   alveolar    clefts    in    in- 
fants, 228 
of  deformity  of  the  nose,  236 
of  double  alveolar  clefts,  229 
of  harelip,  231 

of  open  bite  by  surgical  operation, 
310 
by  traction,  310 
of  protrusion  of  the  lower  jaw  by 
surgical  operation,  301 
by  traction,  300 
of  the  lower  jaw  by  surgical  oper- 
ation, 289 
by  traction,  289 
of  single  alveolar  clefts,  229 
Cracking  of  the  jaw,  313 
Cryer  splint,  119,  123 
Cysts,  40 
dental,  435 


Cysts — cont'd 
dermoid,  487 
of  the  antrum,  425 

treatment  of,  426 
of  the  floor  of  the  mouth,  484 
of  the  gums,  428 
of  the  lips,  471 
of  the  salivary  glands,  500 
of  the  thyroglossal  tract,  544 

near  the  foramen  cecum,  544 

perihyoid,  545 

treatment  of,  546 
of  Wharton's  duct,  486 


D 


Dactylocostal  rhinoplasty,  334 
Davies-Colley  operation  for  cleft  pal- 
ate, 193 
Davenport  splint,  121 
Dawbarn,    plan    of    sequestration    of 

blood, 46 
Deep  scars  on  the  face,  276 
Defects   at   the   angle   of  the   mouth 
and  of  the  cheek,  257 
in  the  lips,  cheeks,  and  palate,  re- 
pair of  acquired,  248-278 
Deformities   of  the  jaws,  after-treat- 
ment of  operation  on,  312 
atypical,  312 

preoperative     considerations     of, 
312 
of  the  maxillae,  288 
of  the  nose,  correction  of,  236 
depressed  bridge,  330 
due  to  loss  of  soft  tissue,  334 
prominence  of  the  bridge,  333 
of  the  tongue,  congenital,  524 
Deformity,  prevention  of,  in  excisions 

of  the  jaw-bones,  463 
Denker  operation  for  chronic  antral 

infection,  723 
Dental  arches  and  the  jaws,  malrela- 
tion  of,  281 
cysts,  435 
splints,  107 
Depressed  bridge  of  nose,  treatment 

of,  330 
Derangement,  motor,  634-643 
Dermoid  cysts,  487 

treatment   of  sinuses   leading   to 
suppurating,  490 
Desquamation,  363 
Diacetie  acid,  von   Jaksch's  test  for, 

64 
Diagnosis  of  branchial  fistula,  609 
of  carcinoma  of  the  lip,  474 
of  the  tongue,  564 
differential,  565 
early,  553 
microscopical,  567 
of     cavernous      angioma     of     the 
tongue,  541 


INDEX. 


717 


Diagnosis — cont'd 

of  condition  of  pulp,  as  developed 

by  Prinz,  17 
of  condition  of  teeth,  16 
of  fractures  of  the  lower  jaw,  98 
x-ray  in,  98 
of  the  upper  jaw,  87 
of  obstruction  of  the  ducts  of  the 

salivary  glands,  501 
of  ranula,  486 
of  salivary  fistula,  506 
of  shock, 57 
of  tic  douloureux,  649 
of  tuberculous  adenitis,  594 
Diet  in  treatment  of  fracture  of  lower 

jaw,  129 
Diphtheria,  358 
Disarticulation  of  the  mandible,  462 

mortality,  462 
Diseases   of   the   gingivae   and   peri- 
dental membrane,  379 
Dislocation  of  the  lower  jaw,  146-152 
backward,  146 
chronic,  152 
forward,  147 
kinds  of,  146 
outward,  147 
reduction    by   manipulation,    151 

by  traction,  150 
retention  of,  151 
Stimson  on,  149 
subluxation  of,  152 
symptoms  of  anterior,  150 
treatment  of,  150 
unreduced, 152 
upward,  146 
Displacement    in     fractures     of    the 
lower  jaw,  93 
of  the  upper  jaw,  86 
Dowd,    operation    for    carcinoma    of 

lower  lip,  482 
Drainage  of  wounds,  71 

rubber   dam,   for   alveolar   abscess, 
393 
Dressings,  80 

sterilization  of,  44 
Dyspeptic  tongue,  527 


E 


Edema  of  the  lungs,  63 
Electrical    tests    for    paralytic    affec- 
tions, 634 
Elevator,  Bartlett,  204 

Brophy,  204 
Elevators  for  extraction  of  teeth,  342 
Embolism,  air,  59 

experiments  in,  59-61 
Empyema,  34 

Endothelioma,  41,  439,  472 
Epidemic  parotitis,  493 
Epithelial  tumors,  516 


Epulis,  428 

treatment  of,  428 
Erb's  scars,  531 
Erythema  migrans  linguae,  528 

multiforme,  353 
Ether  in  general  anesthesia,  692 
Ether  vapor   spray  in   general  anes- 
thesia, 692 
Ethyl  chlorid  in  local  anesthesia,  676 
Etiology  of  carcinoma  of  the  tongue, 

551 
Eustachian  canal,  607 

cushion,  607 
Examination  of  adults,  1 
of  children,  1 
of  infants,  1 
of  tumors,  2 
of  ulcers,  2 
physical,  1 
Excision    of    growths    and    ulcers    of 
doubtful  character  of  the  lip, 
477 
of  indolent  carcinoma  of  the  lip,  478 
of  indurating  carcinoma  of  the  lip, 

478 
of  jaw-bones,  454 

prevention  of  deformity  in,  463 
of  the  mandible,  461 
of  the  maxilla,  454 
of  the  parotid  gland,  517 
of  the  sublingual  gland,  523 
of  the  submaxillary   gland,   522 
of  the  tongue,  bilateral,  587 
Kocher's  normal,  588 
V-shaped,  581 
Explosive  shells,  wounds  due  to,  67 
Extraction  of  teeth,  340-347 
bleeding  in,  control  of,  50 
elevators  in, 342 
forceps  in,  341 
impacted,  345 
instruments  in,  340 
reasons  for,  340 
temporary,  343 
Exudative  stomatitis,   350 


F 


Facial-accessory    nerve    anastomosis, 
639 
artery,  constriction  of  the,   630 

ligation  of  the,  630 
clefts,  congenital,  153-169 
clinical  types  of,  163 
Merkel's  plan  of,  154 
morphology  of,  153 
theories  of,  164 
types  of,  155 
hypoglossal  anastomosis,  639 
nerve  affections  of  the,  636 
prognosis  of,  637 
symptoms  of,  637 


718 


INDEX. 


Facial-accessory   nerve,   affections   of 
the — cont'd 
treatment  of,  638 
tic,  641 

prognosis  of,  643 
treatment  of,  643 
Farcy,  558 
Fauces,  anatomy  of  the,  14 

pharyngeal    wall    and    velum,    ad- 
hesions of,  615 
prognosis  of,  618 
treatment  of,  616 
Faure,  excision  of  the  parotid  gland, 

520 
Feeding  during  treatment  of  fracture 

of  the  lower  jaw,  128 
Ferguson,  theory  of  relation  of  alve- 
olar cleft  to  teeth,  161 
Fibroma,  429 

nasopharyngeal,  621 
treatment  of,  622 
of  the  tongue,  544 
retromaxillary,  treatment  of,  451 
Fibrous  odontoma,  432 
Field,  operative,  preparation  of,  43 
Fifth  cranial  nerve,  644 

injection    of   the    peripheral 
branches  of  the,  653 
of  the  trunks  of  the,  657 
major  neuralgia  of  the,  645 
diagnosis  of,  649 
symptoms  of,  645 
Fissures  of  the  tongue,  525 
syphilitic,  535 
tuberculous,  533 
Fistula,  branchial,  608 
diagnosis  of,  609 
treatment  of,  609 
salivary,  505 

conversion  of  an  external  into  an 

internal,  508 
diagnosis  of,  506 

reconstruction  of  the  distal  part 
of     the     duct     from     buccal 
mucosa  in,  510 
repair  of  the  duct  in  a,  509 
transplantation  of  the  end  of  the 
proximal  part  of  the  duct  in- 
to the  buccal  mucosa  in,  510 
treatment  of,  507 
Fixation,  direct,  in  fractures  of  the 
lower  jaw,  100 
indirect,  in  fractures  of  the  lower 
jaw,  99 
Fixing    of    the    lower    to    the    upper 

jaw,  100 
Flap  sliding  operation  for  congenital 
facial  clefts,  205 
transplantation  for  oral  scar  bands, 
319 
Flaps,  repair  by,  from  other  than  pal- 
ate tissue,  176,   223 
from  palate  tissues,  173 


Flaps — cont'd 

principles   of,   in   congenital   pal- 
ate clefts,  170-178 
transplantation  of  skin-  or  mucus- 
covered,  249 
after-treatment  of,  278 
blood  supply  of,  257 
cheek  flaps  in,  252 
neck  flaps  in,  253 
preparation  of  margins  of  the 

defect  in,  250 
preservation    of   the    epithelial 

lining  in  the  mouth  in,  251 
preservation    of    the    m  o  t  a  r 

nerves  in, 251 
shoulder   and   chest    flaps,    256 
Follicular  odontoma,  431 

compound,  432 
Foot  and  mouth  disease,  359 
Forceps  in  extraction  of  teeth,  341 
Fordyce's  disease,  353 
Forehead  flaps,  252 
Foreign  body,  possible  presence  of,  68 
Fossa  of  Rosenmiiller,  607 
Fracture  bands,  Angle,  100 
of  the  alveolar  process,  85 
of  the  teeth,  85 
treatment  of,  85 
Fractures  of  the  lower  jaw,  93-130 
at    angle,    operation    for    wiring 

the  bones,  104 
care  of  the  mouth,  128 
care  of  the  tissues  in,  126 
character  of  the  injury,  93 
delayed  union  in,  136 
dental  splints  in,  107 
diagnosis  of,  98 
direct  fixation  in,  100 
displacement  in,  93 
feeding  during  treatment  in,  128 
fixing  lower  to  upper  in,  100 
Gunning  splint  in,  114,  115 
gunshot  fractures,  136 
Hammond  wire  splint  in,  107 
Hullihan     continuous     dental 

splint  in,  116 
indirect  fixation  in,  99 
Kingsley  splint  in,  115 
Lane's  plate  in,  106 
malunion  in,  136 
operation  of  wiring  the  jaw  at  or 
in  front  of  the  second  molar, 
106 
time  required  for  union,  135 
treatment  of,  99 

complicated  by  loss  of  bone,  135 
individual  fractures  in,  131 
without  loss  of  substance,  131 
x-ray  diagnosis  of,  98 
of  the  mandible,  93-130 
of  the  nose,  328 
early  cases,  328 
old,  with  deformity,  329 


INDEX. 


719 


Fractures  of  the  nose — cont'd 
treatment,  328 
of  the  ramus,  97,  126,  133 
of  the  upper  jaw,  86-92 
care  of  the  tissues  in,  88 
character  of  the  injury  in.  86 
diagnosis  of,  87 
displacement  in,  86 
Kingsley  splint  in,  91 
Marshall's  method  in,  90 
treatment  of,  87 
mechanical,  89 
Frisch,  bacillus  of,  360 
Furuncle  of  the  lips,  470 


G 


Gag,  Lane,  200 
Owen-Smith,  201 
Whitehead,  201 
Gangrene,  354 
definition  of,  32 
gas,  73 

of  the  lips,  470 
treatment  of,  355 
Gas  bacillus  infection,  73 

gangrene,  73 
Gasserian  ganglion,  operation  of  cut- 
ting the  posterior  root  of  the, 
668 
Gelatin     for    prevention     of    hemor- 
rhage, 47 
General  anesthesia,  691-696 
Geographical  tongue,  528 
German  measles,  357 
Gigli  saw,  292,  307 

Gilmer     method     of     reconstructing 
dental  arches,  109 
of  wiring  lower  to  upper  jaw,  100 
modification  of  Garretson's  use  of 

lead  plates,  236 
posterior  band  splint,   116 
Gingivae,  diseases  of,  379 
Gingivitis,  acute  ulcerous,  379 
treatment,  403 
cause  of,  380 
treatment,  403,  404 
Gland,  parotid,  anatomy  of,  24 
invasion  and  excision  of,  517 
submaxillary,  anatomy  of,  24 
invasion  and  excision  of,  522 
Glanders,  358 

Glands,  Bochdalek's,  anatomy  of,  6 
of  Nuhn  and  Blandin,  anatomy  of,  5 

calculi  in,  502 
salivary,  actinomycosis  of,  500 
acute    suppurative    inflammation 

of  the,  493 
adenoma  of  the,  516 
affections  of  the,  492-523 
anatomy  of  the,  24 
carcinoma  of  the,  516 


Glands,  salivary — cont'd 

chronic  inflammation  of  the,  498 

cysts  of  the,  500 

foreign  bodies  and  stones  in  the, 

502 
inflammation  of  the  larger  ducts 

of  the,  492 
inflammatory  tumors  of  the,  498 
obstruction  of  the  ducts  of  the, 
500 
diagnosis  of,  501 
treatment  of,  501 
secondary  infections  of  the,  494 

treatment  of,  494 
speciflc  Infections  of  the,  499 
syphilis  of  the,  500 
tuberculosis  of  the,  499 
tumors  of  the,  513 
benign, 513 
epithelial,  516 
inflammatory,  498 
mixed,  513 
wounds  in  the,  505 
Glossitis,  chronic  superflcial,  528 
Moeller's,  532 
sclerosing,  535 
Glossodynia  exfoliativa,  533 
Gloves,  rubber,  sterilization  of,  44 
Goiter,  lingual,  544 

retropharyngeal,  622 
Gonorrhea,  358 
Grafts,  bone,  249 

combined  pedicled  bone  and  soft 

tissue,  269 
fixation  of  maxilla,  272 
free,  264 

preparation  of  wound  for  recep- 
tion of,  266 
repair    of    defects    in    the    lower 

jaw,  266 
repair    of    defects    in    the    upper 

jaw,  265 
semipedicled,  267 
transplantation,  273 
cartilage,  249 

combined  bone  and  soft  tissue,  249 
soft  tissue,  248 
Thiersch,  249 
Granulations  in  wounds,  74 
Graves  scaphoid  scapula,  168 
Guilford's  articulator.  111 
Gumma  of  the  mouth,  365 

of  the  tongue,  536 
Gums,  abscess  of,  18 
anatomy  of,  17 
hypertrophy  of  the,  427 
mucous  cysts  of  the,  428 
Gunning  splint,  114,  115 
Gunshot   fractures   of  the  jaw-bones, 
136 
bandaging,  145 
complications  in,  139 
fixation  in,  137, 138 


(20 


INDEX. 


Gunshot  fractures — cont'd 

general  treatment  at  base  hospital, 
138 

methods  of  fixation,  142 

old  fractures,  144 

orthopedic  splints,  145 

plastic  operation,  140 

recent  fractures,  142 
Gunshot  wounds,  66 

H 

Hairy  tongue,  532 
Hammond  splint,  107 
Hammond-Robert's  palate  clamp,  197 
Hand  grenade,  wounds  due  to,  67 
Hands,  surgeon's,  preparation  of,  42 
Harelip,  155 

correction  of,  231 
double,  operation  for,  234 
Owen  operation  for,  234 
Rose  operation  for,  233 
Hayes  splint,  118,  122 
Healing  of  wounds,  73 
Heat  as  symptom  of  inflammation,  29 
Hemangioma  of  the  lips,  471 
Hemorrhage,  46 

application  of  cold  for,  50 
control  of,  48 

of  carcinoma  of  the  tongue,  559 
postoperative,  51 

in  palate  cleft  operations,  215 
prevention  of,  46 

animal  serum  for,  48 
calcium  lactate  for,  47 
defibrinated    blood     transfusions 

for,  48 
gelatin  for,  47 

sequestration  of  blood  for,  46 
secondary,  52 

treatment  of  effects  of,  52 
vasoconstrictor  drugs  in,  51 
Heredity,  influence  of,  on  failure  of 

cleft  closure,  164 
Herpes,  350 

Butlin's  ointment  for,  351 
of  the  lips,  470 
Herpin  splint,  133 
Hilton,  method  of  intraoral  incision, 

397 
Horsley,   formula   for   arterial   bleed- 
ing, 48 
Holzphlegmon,  411 
Hullihan  splints,  116 
Hutchinson  teeth,  16 
Hyperemia,  Bier's,  for  inflammations, 

36 
Hypertrophy  of  bone,  390 
of  the  gums,  427 
of  the  lips,  simple,  469 
pseudo,  499 
Hypodermic  armamentarium  in  local 
anesthesia,  681 


Hypoglossal  nerve,  affections  of  the, 

641 
Hysterical  closure  of  the  jaws,  314 


Ichthyosis  of  the  tongue,  532 
Immunity,  acquired,  28,  29 

inherited,  28,  29 
Impacted  teeth,  345 

after-treatment  of,  347 
removal  of,  347 
treatment  of,  346 
indications  for,  346 
Implantation  of  teeth,  84 
Incised  wounds,  65 
Incisive  glands,  anatomy  of,  5 
Indentations  of  the  tongue,  525 
Individual  fractures,  131 
Induration     of     carcinoma     of     the 

tongue,  556 
Infants,    correction   of  alveolar   cleft 
in, 228 
examination  of,  1 
Infection,  agencies  of,  32 
antral,  418 

as  a  cause  of  cleft  closure,  168 
deflnition  of,  32 
from  earth,  67 

in   carcinoma   of  the  tongue,   lym- 
phatic, 559 
inflammation  accompanying,  28 
of  a  wound,  69 
spread  of,  32        * 
Infections,  32 

of  bone,  speciflc,  388 

treatment  of,  407  • 

of  floor  of  the  mouth,  409 
of  the  jaw-bones,   371 

treatment  of,  392 
of  the  mouth,  348 
of  the  neck, 409 
of  the  peridental  tissues,  371 

treatment  of,  392 
of  the  pharynx,  acute,  611 
of  the  salivary    glands,    secondary, 
494 
specific,  499 
treatment  of,  494 
of  the  teeth, 371 

treatment  of,  392 
septic,   of  the   floor   of  the   mouth 

and  neck,  409 
specific,  357 
treatment  of,  35,  407 
by  antitoxins,  37 
by  cold,  36 
by  heat,  36 
by  hyperemia,  36 
by  surgery,  35 
Infiltration  anesthesia,  695 
Inflammation,  28 
accompanying  an  infection,  28 


INDEX. 


r2i 


Inflammation — cont"d 
from  irritation,  28 
good  or  harm  from,  31 
of  the  bone,  383 

of  the  salivary      glands,      chronic, 
498 
of  the  larger  ducts  of,  492 
of    the    submaxillary    and    sublin- 
gual   glands    in    young    in- 
fants, 493 
results  of,  30 
symptoms  of,  30 
Inflammations  of  the  mouth,  348 
of  the  tongue,  527 
treatment  of,  35 
Inflammatory  tumor  of  the  salivary 

glands,  498 
Injection    in    local   anesthesia,    intra- 
osseous, 686 
peridental,  685 
perineurial,  686 
subperiosteal,  684 
technique  of,  683 
of    paraffin,    for    obliquity    of    the 
chin,  297 
postpharyngeal,  247 
of  the  auriculotemporal  nerve,  654 
of  the  descending    palatine    nerve, 

655 
of  the  flfth  nerve,  mandibular  di- 
vision, 657 
ophthalmic  division,  662 
peripheral  branches,  653 
superior  maxillary  division,   660 
trunks,  657 
of  the  inferior  dental  nerve,  654 

mental  branch,  654 
of  the  infraorbital  nerve,  654 
of  the  lingual  nerve,  655 
of  the  long  buccal  nerve,  656 
of  the  nasal  nerve,  653 
of  the  orbital  branch  of  the  supe- 
rior maxillary  nerve,  654 
of  the  palatine  branch  of  the  naso- 
palatine nerve,  656 
of  the  sphenopalatine  ganglion,  660 
of  the  supraorbital  nerve,  654 
of  the  supratrochlear  nerve,  654 
Injuries  of  the  alveolar  process,  83 
of  the  lips,  468 
of  the  pharynx, 611 
of  the  soft  parts,  65 
of  the  teeth, 83 
Injury   as   cause    of    failure    of   cleft 

closure,  168 
Instruments   in    extraction    of   teeth, 
340 
in  cleft  palate  operations,  200 
sterilization  of,  44 
Insufflation,    general    anesthesia    by, 

693 
Intracranial  operations,  666 


Intraoral    operation    for    removal    of 

the  tongue,  581 
Intratracheal  anesthesia,  693 
Intravenous  transfusion,  53 
Irregular  setting  of  the  teeth,  causes 

for,  280 


Jacobson  pharyngotomy,  624 
Jaksch,  v.,  test  for  diacetic  acid,  64 
Jaw,  ankylosis  of,  operations  for,  322 
gunshot  fractures  of,  136 
lower,  carcinoma  of  tiie,  441 

disarticulation  of  half  of  the,  452 
dislocation  of,  146-152 
backward,  146 
chronic,  152 
forward,  147 
kinds  of,  146 
outward,  147 

reduction  by  manipulation,  151 
reduction  by  traction,  150 
retention  of,  151 
Stimson  on,  149 
subluxation  of,  152 
symptoms  of  anterior,  150 
treatment  of,  150 
unreduced, 152 
upward,  146 
excision  of  the.  461 
fractures  of,  93-130 

at  angle,  operation  for  wiring 

the  bone,   104 
care  of  the  tissues  in,  126 
character  of  the  injur}%  93 
delayed  union  in,  136 
dental  splints  in,  107 
diagnosis  of,  98 
direct  fixation  in,  100 
Lane  plates  in,  106 
malunion  in,  136 
operatioii  of  wiring  the  jaw  at 
or    in    front    of    the    second 
molar,  106 
time  required  for  union,  135 
treatment  of,  99    • 
treatment    of,    complicated    by 

loss  of  bone,  135 
treatment    of    individual    frac- 
tures in,   131 
wiring  lower  to  the  upper  in, 

106 
x-ray  in  diagnosis  of,  98 
protrusion  of  the,  284,  300 
Babcock's  operation  for,  309 
correction    by    surgical    opera- 
tion, 301 
correction  by  traction,  301 
submucoperiosteal  operation 

for,  306 
transmucoperiosteal    operation 
for.  305 


(22 


INDEX. 


Jaw.  lower — cont'd 

retraction  of  the,  285,  288 

correction    by    surgical    opera- 
tion, 289 
correction  by  traction,  289 
operation  for,  292 
undeveloped,  x-ray  of,  279 
upper,  carcinoma  of,  440,  441 
fractures  of,  86-92 

care  of  the  tissues  in,  88 
character  of  the  injury  in,  86 
diagnosis  of,  87 
displacement  in,  86 
Kingsley  splint  in,  91 
Marshall's  method  in,  90 
treatment  of,  87 
Jaw-bones,  excisions  of  the,  454 
prevention  of  deformity  in,  463 
infections  of  the,  371 

treatment  of,  392 
resections  of  the,  454 
tumors  of  the,  427 
Jaws,  anatomy  of,  22 

closure  of  the  hysterical,  314 
deformities  of  the.  after-treatment 
of  operations  on,  312 
atypical,  311 

preoperative     considerations     of, 
311 
limitation  of,   due  to  reflex   irrita- 
tion, 314 
due  to  scar  bands  or  ankylosis, 
317 
malrelation  of  the,  and  the  dental 
arches,  281 
indications    for    surgical    opera- 
tions for,  286 
orthodontia  in  the  treatment  of, 
286 
Junker  apparatus  for  anesthesia,  183 


K 


Kaufmann,  method  of  conversion  of 
and  external  into  an  internal 
salivary  fistula,  508 

Keloid  of  the  tongue,  544 

Keratosis,  528 

Kingsley  splint,  91,  115 

Klebs-Loffler  bacillus,  358 

Koch's  serum  reaction,  364 

Kocher      normal      excision      of     the 
tongue,  588 
operation     for     resection     of     the 
tongue  at  the  root,  589 

Kolliker,  theory  of  relation  of  alveo- 
lar cleft  to  teeth,  162 

Koplik's  spots,  357 

Krause,  operation  for  extirpation  of 
Gasserian  ganglion,  670 


Kiister,  operation  for  chronic  antral 
infection,  423 
operation     for     congenital     palate 
clefts,  217 


Lane  gag,  200 

operation  for  palate  and  lip  clefts, 

192 
plates,  106 
Langenbeck    low    lateral    pharyngot- 
omy,  627 
operation     for     congenital     palate 

clefts,  207 
operation  for  salivary  fistula,  510 
Legal's  test  for  acetone,  64 
Leontiasis  ossea,  391 
Leprosy,  359 
Leptothrix,  369 
Leucoma,  529 
Leucoplakia,  350,  529 
Lewisohn's  method  of  sodium  citrate 

blood  transfusion,  55 
Lichen    planus,   353 
Ligation  of  arteries,  52,  629 
common  carotid,  633 
coronary,   630 
external  carotid,   631 
facial,   630 
lingual.  630 
temporal,  630 
Limitation  of  jaws,  due  to  reflex  irri- 
tation, 314 
due  to  scar  bands  or  ankylosis, 

317 
due  to  war  injuries,  315 
Lingual  artery,  constriction  of,  630 
ligation  of,  630 
goiter,  544 

operation,      difficult     respiration 
after  a,  240 
pits,  congenital,   169 
restoration  of  the  lower,  260 

Burow-Stewart      operation      for, 

262 
of  the  upper,  277 
scars,  468 
Lipoma,  429 

of  the  tongue,  543 
Lips,  anatomy  of,  20 
angioma  of  the,  471 
blood  supply  of  the,  21 
cancer  of  the,  474-483 
carbuncle  of  the,  470 
carcinoma  of  the,  474-483 
diagnosis  of,  474 

excision  of  growths  and  ulcers  of 
doubtful  character,  477 
of  indolent,  478 
of  indurating,  478 
operation  for  early  indurated,  478 
where    repair    is    to    be    made 


INDEX. 


Lips,  carcinoma  of — cont'd 

with  flaps  from  the  neck,  482 
prognosis  of,  483 
treatment  of,  475 
chaps  of  the,  468 

congenital  clefts  of  the,  after-treat- 
ment of,  240 
operative  correction  of,  227 
results  of,  241 
cracks  of  the,  468 
cysts  of  the,  471 
diseases  of  the,  468 
endothelioma,  472 
furuncle  of  the,  470 
gangrene  of  the,  470 
hemangioma  of  the,  471 
herpes  of  the,  470 
hypertrophy,  simple,  469 
injuries  of  the,  468 
macrocheilia,  469 
papillomata  on  the,  473 
perleche,  470 
phlegmon  of  the,  470 
scars  on  the,  468 
syphilis  of  the,  471 
tuberculosis  of  the,  470 
tumors  of  the,  468 
warts  on  the,  473 
Local  anesthesia,  675-690 

absorption  of  poisonous  drugs  in, 

677 
adrenalin  in,  676 
anesthetization    of    the    pulp    in, 

687 
cocain  in, 677 
ethyl  chlorid  in,  676 
for  anesthetizing  the  skin,  689 
for.  operations  about  the  mouth, 

689 
hypodermic    armamentarium    in, 

681 
intraosseous  injection  in,  686 
means  of  producing,  675 
novocain  in, 677, 679 
peridental  injection  in,  685 
perineurial  injection  in,  686 
preparation  of  solution  in,  678 
subperiosteal  injection  in,  684 
technique  of  injection  in,  683 
Lockjaw,  72 
Loosening  of  the  teeth,  84 

treatment  of,  84 
Lower  lip,  restoration  of,  260 
Ludwig's  angina,  410 
Lungs,  edema  of,  63 
Lupus  of  the  mouth,  364 
Lymph  nodes,  anatomy  of,  26 
Lymphangiomatous  macroglossia,  537 

treatment  of,  538 
Lymphatic  infection  in  carcinoma  of 

the  tongue,  559 
Lymphatics,  cervical,  malignant  dis- 
eases of  the,  593 


Lymphatics — cont'd 

radical  operation  for  tuberculous 
infection  of  the,  597 
results  of,  602 
secondary  carcinoma  of  the,  603 
results  of  operation  on,  605 
treatment  of,  603 
tuberculosis  of  the,  593 
Lymphosarcoma  of  the  pharynx,  623 


M 


Macrocheilia,  469 

Macroglossia,   lymphangiomatous,  537 
treatment  of,  538 
simple  muscular,  539 
Macrostomia,  156 

Malformations   of  the   pharynx,   con- 
genital, 607 
Malignant  tumors,  40 

of  the  pharynx,  623 
Malleus,  358 
Malnutrition   as   cause   of   failure   of 

cleft  closure,  167 
Malocclusion,  280 

Malrelations  of  the  jaws,  and  of  the 
dental  arches,  281 
indications    for    surgical    opera- 
tion for,  286 
orthodontia  in  the  treatment  of, 
286 
Malunion   in   fractures   of  the   lower 

jaw,  136 
Mandible,  carcinoma  of  the,  441 
disarticulation  of  half  the,  462 
dislocation  of  the,  146-152 
excision  of  the,  461 
fractures  of  the,  93-130 
protrusion  of  the,  284,  300 
retraction  of  the,  285,  288 
Marshall,  method  in  fractures  of  the 

upper  jaw,  90,  91 
Marten  splint,  141 
Maternal    impressions    as    cause    of 

failure  of  cleft  closure,  167 
Maxilla,  excisions  of  the,  454 
resection  of  the,  454 
total,  458 

upper  part  of,  457 
Maxillae,    approximation    of    the,    in 
congenital  palate  clefts,  221 
deformities  of  the,  288 
Maxillary  antrum,  418 
anatomy  of,  23,  418 
sinus,  diseases  of  the,  418-426 
Measles,  357 

German,  357 
Mechanical  abrasions  of  the  teeth,  83 
Mechanical  cause  in  failure  of  cleft 

closure,  165 
Mechanical  treatment  of  fracture  of 

upper  jaw,  89 
Mercurial  stomatitis,  353 


724 


INDEX. 


Mercury  poisoning,  387 
Metallic  poisoning,  353,  387 
Microorganisms  of  suppuration,  33 
Mikulicz's  disease,  499 

high  lateral  pharyngotomy,  625 
IMineral  poisons,  353,  387 
Mixed  tumors  of  the  salivary  glands, 

513 
Moeller's  glossitis,  532 
Morawitz,  defibrinated  blood  transfu- 
sion as  a  styptic,  48 
^lorphology      of      congenital      facial 

clefts,  153 
Mortality  of  operations  on  congenital 

palate  clefts,  197,  216 
Motor  derangement,  634-643 
Moullin,  description  of  shock,  57 
Mouth,  actinomycosis  of  the,  369 
anatomy  of,  2 
and  the  cheek,  closure  of  defects  at 

the  angle  of  the,  257 
carcinoma  of  the,  443 
chancre  of  the,  366 
floor  of  the,  anatomy  of,  4 
carcinoma  of  the,  491 
cysts  of  the,  484 
infections  of  the,  409 
tumors  of  the,  484 
benign, 491 
malignant,  491 
gumma  of  the,  365 
infections  of  the,  348 
inflammation  of  the,  348 
local     anesthesia     for     operations 

about  the,  689 
lupus  of  the,  364 
method  of  washing  a  baby's,  349 
parasites  of  the,  367 
Serre   operation    for   restoring   the 

angle  of  the,  258 
syphilis  of  the,  365 
tuberculosis  of  the,  363 
tumors  of  the,  427 
vestibule  of  the,  anatomy  of,  19 
Mucolofibrinous  stomatitis,  352 
Mucous  cysts  of  the  gums,  428 
membrane  of  thj  mouth,  373 
patch  of  the  tongue,  534 
Mucus-covered    flaps,    transplantation 

of  skin-  or,  249 
Mutilocular  cystic  tumors,  439 
Mumps,  493 

Murphy  method  of  proctoclysis,  54 
Muscles  of  mastication,  anatomy  of, 
24 
speech,  physiological  action  of,  24 
Mush  bite,  114 
Myeloma,  439 
Myxoma,  431 
Myxosarcoma,  431 


N 


Nares,  atresia  of  the  posterior,  607 

osseous  obstruction  of  the,  288 
Nasopharyngeal  fibroma,  621 
treatment  of,  622 
polypus,  621 

treatment   of,  622 
Neck,  infections  of  the,  409 
Neck  glands,  delayed  infection  of  the, 

449 
Necrosis,  386 
definition  of,  32 
treatment  of,  396 

by    removal    of    the    sequestrum, 
398 
Nerve    anastomosis,    facial-accessory, 
639 
facial-hypoglossal,  639 
facial,  affections  of,  636 
prognosis  of,  637 
symptoms  of,  637 
treatment  of,  638 
fifth  cranial,  644 

injections  of  the  mandibular  di- 
vision of  the,  657 
of  the   ophthalmic   division   of 

the,  662 
of  the   peripheral   branches   of 

the,  653 
of   the    superior   maxillary    di- 
vision of  the,  660 
of  the  trunks  of  the,  657 
major  neuralgia  of  the,  645 
diagnosis  of,  649 
symptoms  of,  645 
frontal,  avulsion  of  the,  666 
hypoglossal,  affections  of  the,  641 
nasal,  avulsion  of  the,  666 
resection,  666 

trifacial,  affections  of  the,  636 
Neuralgia,  sphenopalatine,  649 
Nevi  of  the  tongue,  capillary,  539 
Nicoladoni,    operation    for    repair    of 

duct  in  salivary  fistula,  509 
Nicoladoni  and  Braun,  reconstruction 
of  distal   part   of  duct   from 
the   buccal   mucosa   for   sali- 
vary fistula,  510 
Nitrous   oxid    in    general   anesthesia, 

695 
Nodes,  lymph,  anatomy  of,  26 
Nodules  of  the  tongue,  525 
Noguchi  reaction,  366 
Noma,  355 

treatment  of,  356 
Nose,  correction  of  deformity  of  the, 
236 
deformities  of  the,  328 
depressed  bridge,  330 
due  to  loss  of  soft  tissue,  334 
prominence  of  the  bridge,  333 


INDEX. 


725 


Nose — cont'd' 
deviated,  Senseny's  plan  of  replac- 
ing a,  239 
Novocain  in  local  anesthesia,  677,  679 
Nulin  and  Blandin,  glands  of,   anat- 
omy of,  5 
calculi  in,  502 

O 

Obliquity  of  the  chin,  296 

paraffin  injection  for,  297 
transplantation  of  bone  or  carti- 
lage for,  298 
Obstruction  of  the  nares,  osseous,  288 
Obturator,  Warnekros,  244 
Obturators,  242 

versus  operation,  247 
Occlusion,  ideal,  279 
Odontoma,  431 
composite,  433 
fibrous,  432 
follicular,  431 

compound,  432 
radicular,  433 
treatment  of,  434 
Oidium  albicans,  367 
Open  bite,  285,  310 

correction  by  surgical  operation, 
310 
by  traction,  310 
operation  for,  310 
fixation  in,  310 
Operation  about  the  mouth,  local  an- 
esthesia for,  689 
for  ankylosis  of  the  jaw,  322 
for  carcinoma  of  the  lip,  early  in- 
durated, 478 
where    repair    is    to    be    made 
with  neck  flaps,  482 
of  the  tongue,  results  of,  570 
local,  447 
radical,  446 
for  chronic   antral   infection,    Can- 
field-Ballenger,  425 
Caldwell-Luc,  423 
Denker,  423 
Kiister,  423 
for  congenital  palate  clefts,  advan- 
tages of  very  early,  180 
Brophy,  184 
choice  of,  195 
Davies-Colley,  193 
flap  sliding,  205 
in  early  infancy,  182-197 

preparation  for,  182 
in  extraordinary  cases,  217-226 
in  ordinary  cases  after  early  in- 
fancy, plastic,  198-216 
preparation  for,  199 
Kiister,  217 
Lane,  192 
Langenbeck,  207 
mortality  of,  216 


Operation  about  the  mouth  for  con- 
genital  palate   clefts — confd 
preferable  age  for,  179 
two-step,  217 
for  double  harelip,  234 
for  fracture  of  the  lower  jaw,  wir- 
ing the  bone,  104 
for  harelip,  Owen,  234 

Rose,  233 
for  malrelation   of  the  jaws,   indi- 
cations for,  286 
for  open  bite,  310 
fixation  in,  310 
for  oral  scar  bands  by  flap  trans- 
plantation, 319 
for  protrusion    of    the    lower    jaw, 
Babcock's,  309 
submucoperiosteal,  306 
adjusting  the  bone,  307 
cutting  the  bone,  306 
intraoral  fixation,  308 
transmucoperiosteal,  305 
cutting  the  bone,  305 
fixing  the  jaw,  305 
for  removal  of  the  tongue,  580 
anesthesia  in,  581 
excision  of  one-half  of  body,  583 
general  preparation  for,  580 
intraoral,  551 
local  preparation  for,  580 
position  on  the  table  in,  581 
V-shaped,  581 
for  restoring     the     angle     of     the 
mouth,  257 
the  lower  lip,  Burow-Stewart,  262 
for  retraction  of  the  lower  jaw,  292 
adjusting  the  bone  in,  294 
cutting  the  bone  in,  292 
intraoral  fixation  in,  295 
for  tuberculous  adenitis,  597 

results  of,  602 
in    infection    of   the    cervical    lym- 
phatics, 602 
results,  602 
intracranial,  666 

lip,  difficult  respiration  after  a,  240 
obturators  versus,  247 
of  cutting  the  posterior  root  of  the 

Gasserian  ganglion,  668 
of  wiring  the  jaw  at  or  in  front  of 
second  molar,  106 
Operative     correction    of    congenital 
clefts  of  the  lip  and  alveolar 
process,  227 
field,  preparation  of,  43 
treatment  of  oral  scar  bands,  318 
Orbicularis  oris,  20 

Orthodontia     in     the     treatment     of 
malrelations  of  the  jaws,  286 
Orthopedic  splints,   145 
Osseous  obstruction  of  the  nares,  288 
Osteitis,  383 
postfebrile,  389 


736 


INDEX. 


Osteoma,  430 

Osteoplastic  resections,  459 

mortality  of,  460 

prognosis  of,  461 
Owen  operation  for  harelip,  234 
Owen-Smith  gag,  201 


Pain,  2 

as  symptom  of  inflammation,  29 
of  carcinoma  of  the  tongue,  556,  558 
referred,  2 
Palate  adenoma,  621 
treatment  of,  621 
and   alveolar  process,    resection   of 

the,  455 
anatomy  of  the,  12 
clamp,  Hammond-Roberts,  197 
clefts,  congenital,  170-226 

advantages  of  very  early  oper- 
ation for,  180 
after-treatment  of.  195,  215 
anatomical    considerations    of, 

170 
approximation  of  the  maxillae 

in, 221 
Brophy  operation  for,  184 
choice  of  operation  for,  195 
consideration    of   various    ages 

for  operation  for,  179 
Davies-Colley     operation      for, 

193 
double,  172 

flap  sliding  operation  for,  205 
instruments  and  materials  for, 

200 
Kiister  operation  for,  217 
Lane  operation  for,  192 
Langenbeck  operation  for,  207 
mortality  in,  216 
mortality     in     operations     for, 

197 
non-union  in,  215 
operations     for     extraordinary 

cases  of,  217-226 
operations  in  early  infancy  for, 

182-197 
plastic  operations  in   ordinary 

cases     after     early     infancy, 

198-216 
position  and  light  in  operation 

on, 199 
postoperative    hemorrhage    in, 

215 
preferable  ages  at  which  to  op- 
erate, 179-181 
preparation  for  operation,  182, 

199 
principles  of  repair  by  plastic 

flaps,  170-178 
reoperation  in,  216 
repair  by  flaps  from  other  than 


Palate  clefts — cont'd 

palate  tissues,  176,  223 
repair  by  flaps  from  palate  tis- 
sues, 173 
results  in,  216 
retention  devices  for,  213 
single,  172 

two-step  operation  for,  217 
perforations  of  the,  277 
speech,  cleft,  245 
Palsy,  Bell's,  636 
Papillomata  of  the  lips,  473 
of  the  tongue,  547 
treatment  of,  548 
Paraffin  injection  for  obliquity  of  the 
chin, 297 
postpharyngeal  injection  of,  247 
Paralysis,  Bell's,  636 
Paralytic  affections,  634 
electrical  tests  for,  634 
treatment  of,  635 
Parasites  of  the  mouth,  367 
Parotid  gland,  anatomy  of,  24 

invasion  and  excision  of,  517 
Parotitis,  493 
Partsch  band,  466 
Passavant's  cushion,  244 
Pearl  worker's  disease,  388 
Pellagra,  352 
Pemphigus,  351 

Perforations  of  the  palate,  277 
Pericementitis,  381 
treatment  of,  405 
Peridental  membrane,  373 

diseases  of,  379 
Peridental  tissues,  infection  of,  371 
Perihyoid  thyroid  tumors  and  glands, 

545 
Peritonsillar  abscess,  612 

treatment  of,  612 
Perleche,  470 
Pharyngeal  pouches,  611 

wall,  velum,  and  fauces,  adhesions 
of,  615 
prognosis  of,  618 
treatment  of,  616 
Pharyngitis,  acute,  611 

phlegnomous,  611 
Pharyngotomy,  624 
high  lateral,  625 
intraoral  removal  in,  624 
low  lateral,  627 
Pharynx,  acute  infections  of  the,  611 
anatomy  of  the,  14,  606 
carcinoma  of  the,  624 
congenital    malformations    of    the, 

607 
diseases  of  the,  606 
injuries  of  the,  611 
lymphosarcoma  of  the,  623 
sarcoma  of  the,  623 
stricture  of  the,  615 
teratomata  of  the,  619 


INDEX. 


727 


Pharynx — cont'd 
tumors  of  the,  619 
benign,  620 
malignant,  623  ■ 
vascular,  620 
Phlegmon  of  the  lips,  470 
Phlegmonous  pharyngitis,  611 

stomatitis,  416 
Phosphorous  poisoning,  387 
Physical  examination,  1 
Physiological   action   of  speech   mus- 
cles, 242 
Pits,  congenital  lip,  169 
Plastic  flaps,  made  from  other  than 
palate  tissue,  176 
made  from  palate  tissue,  175 
principles   of  repair  by,   in   con- 
genital palate  clefts,  170-178 
operations     in    gunshot    fractures, 
140 
in  ordinary  cases  of  palate  cleft, 

after  early  infancy,  198-216 
in  wounds,  77 
Plates,  Lane,  106 
Plaut,  angina  of,  361 
Pneumonia,  postoperative,  62 
Poisoning,  arsenic,  388 
bismuth,  388 
mercury,  387 
phosphorous,  387 
Poisons,  metallic,  387 

mineral,  353,  387 
Polypus,  nasopharyngeal,  621 

treatment  of,  622 
Postfebrile  osteitis,  389 
Postoperative  hemorrhage,  51 

in  operations  on  palate  cleft,  215 
pneumonia,  62 
Postpharyngeal  injection  of  paraffin, 

247 
Pouches,  pharyngeal,  611 
Precancerous  lesions,  446 
Preparation  of  dressings,  44 
of  instruments,  44 
of  operative  field,  42 
of  rubber  gloves,  44 
of  surgeon's  hands,  42 
of  sutures,  45 

of  wound    for    reception    of    graft, 
266 
Prevention  of  deformity,  in  excisions 
of  the  jaw-bones,  463 
of  hemorrhage,  46 

sequestration  of  blood  for,  46 
Prinz,  diagnosis  of  condition  of  pulp, 
17 
extraction   of  teeth,  340 
local  anesthesia,  340 
Probe,  use  of,  68 
Proctoclysis,  54 

method  of  J.  B.  Murphy,  54 
use  of  atropin  after,  54 


Prognosis      of      carcinoma      of      the 

tongue,  569 
Prominence  of  the  bridge,  correction 

of,  333 
Protrusion  of  the  lower  jaw,  284,  300 
Babcock's  operation  for,  309 
correction  by  surgical  operation 
of,  301 
by  traction  of,  300 
submucoperiosteal  operation  for, 
306 
adjusting  the  bone,  307 
cutting  the  bone,  306 
intraoral  fixation,  308 
transmucoperiosteal  operation 
for,  305 
cutting  the  bone,  305 
fixing  the  jaw,  305 
Psoriasis  of  the  tongue,  531 
Puncture  wounds,  65 
Pus  formation,  30,  33 
Pus-forming  organisms,  33 
Pyemia,  32 
Pyorrhea  alveolaris,  17 

R 

Radicular  odontoma,  433 

Ramus,  fracture  of  the,  97,  126,  133 

Ranula,  484 

diagnosis  of,  486 
symptoms  of,  485 
treatment  of,  486 
Raw  tongue,  527 
Redness    as    symptom    of    infiamma- 

tion, 29 
Reduction    of    dislocation    of    lower 
jaw,  by  manipulation,  150 
by  traction,  150 
retention  after,  151 
Rehn's  spots,  357 
Reoperation     in     congenital     palate 

clefts,  216 
Repair    of    acquired    defects    in    the 
hard  and  soft  tissues  of  the 
face,  248 
of  defects  in  the  lower  jaw,  266 
of  defects  in  the  upper  jaw,  265 
Replantation  of  teeth,  84 
Resection,  nerve,  666 

of    the    alveolar    process,    inferior, 
461 
superior,  454 
of  the  jaw-bones,  454 
of  the  mandible,  461 
of  the  maxilla,  454 
after-treatment  of,  459 
total,  458 
upper  part,  457 
of  the  palate  and  alveolar  process, 

455 
of  the  tongue  at  the  root,  Kocher's 
operation,  589 


738 


INDEX. 


Resection — vonfd 
osteoplastic,  459 
mortality  of,  460 
prognosis  of,  461 
Respiration,  difficult,  after  a  lip  oper- 
ation, 240 
Restoration  of  the  lower  lip,  260 

Burow-Stewart  operation  for,  260 
of  the  upper  lip,  277 
Retraction  of  the  lower  jaw,  285,  288 
correction  by  surgical  operation 
for,  289 
by  traction  for,  289 
operation  for,  292 

adjusting  the  bone  in,  294 
cutting  the  bone  in,  292 
intraoral  fixation  in,  295 
Retromaxillary   fibromata,   treatment 
of,  451 
tumors,  450 
Retropharyngeal  abscess,  613 
treatment  of,  614 
goiter,  622 
Rhinoplasty,  dactylocostal,  334 
Rima  oris,  20 

Roberts'    modification    of    the    Ham- 
mond palate  clamp,  197 
Rose  operation  for  harelip,  233 
Rosenmiiller,  fossa  of,  607 
Rubber  gloves,  sterilization  of,  44 
Rubeola,  357 


Saline  transfusion,  53 
Salivary  calculi,  502 
treatment  of,  504 
fistula,  505 

conversion  of  an  external  into  an 

internal,  508 
diagnosis  of,  506 
reconstruction  of  the  distal  part 

of  the  duct  from  the  buccal 

mucosa  in,  510 
repair  of  the  duct  in,  509 
transplantation  of  the  end  of  the 

proximal    part    of    the    duct 

into    the    buccal    mucosa    in, 

510 
treatment  of,  507 
glands,  actinomycosis  of  the,  500 
acute    suppurative    inflammation 

of  the,  493 
adenoma  of  the,  516 
affections  of  the,  492-523 
anatomy  of  the,  24 
carcinoma  of  the,  516 
chronic  inflammation  of  the,  498 
cysts  of  the,  500 
foreign  bodies  and  stones  in  the, 

502 
inflammation  of  the  larger  ducts 

of  the,  492 


Salivary  glands- — cont'd 

inflammatory  tumors  of  the,  498 
pseudohypertrophy,  499 
obstruction  of  the  ducts  of  the, 
500 
diagnosis  of,  501 
treatment  of,  501 
secondary  infections  of  the,  494 

treatment  of,  494 
septic  parotitis,  494 
specific  infections  of  the,  499 
syphilis  of  the,  500 
tuberculosis  of  the,  499 
tumors  of  the,  513 
benign, 513 
epithelial,  516 
inflammatory,  498 
mixed,  513 
wounds  in  the,  505 
Salivation      in     carcinoma     of     the 

mouth,  559 
Salvarsan  in  syphilis,  367 
Sarcina,  370 
Sarcoma,  41,  435 

Coley's  fluid  for,  433 
of  the  pharynx,  623 
of  the  tongue,  549 

treatment  of,  550 
treatment  of,  437 
starvation,  438 
Saw,  Gigli,  292,   307 
Scaphoid   scapula,  Graves,  168 
Scar  bands,  operation  by  flap  trans- 
plantation on,  319 
operative  treatment  of  oral,  318 
or  ankylosis,   limitation  of  jaws 
due  to,  317 
Scarlatina,  357 
Scars  after  wounds,  75 
deep,  on  the  face,  276 
of  the  floor  of  the  mouth,  491 
on  the  lips,  468 
Scleroma,  360 
Sclerosing  glossitis,  535 
Scurvy, 357 

Secondary  hemorrhage,  52 
Semipedicled  bone  grafts,  267 
Senseny,  plan  of  replacing  a  deviated 

nose,  239 
Sepsis,  probability  of,  in  wounds,  69 
Septicemia,  32 
Sequestration  of  blood  for  prevention 

of  hemorrhage,  46 
Sequestrum,  removal  of,  in  treatment 

of  necrosis,  398 
Serre,  operation  for  restoring  the  an- 
gle of  the  mouth,  258 
Serum,    animal,     for    prevention    of 

hemorrhage,  48 
Shock,  56 

depression  in,  57 
diagnosis  of,  57 
excitement  in,  57 


INDEX. 


729 


Shock — cont'd 
fatality  of,  57 
in  burns,  77 

Moullin's  description  of,  57 
treatment  of,  58 
Slirapnel,  wounds  due  to,  66 
Siegel,  bacillus  of,  359 
Sinaple  muscular  macroglossia,  539 
Sinus    leading    to    a    dermoid,    treat- 
ment of,  490 
Skin,  local  anesthesia  for  anesthetiz- 
ing the,  689 
or   mucus-covered   flaps,   transplan- 
tation of,  249 
Slough,  354 

treatment  of,  355 
Sluder  on   sphenopalatine  neuralgia, 

649 
Smallpox,  357 
Smoker's  patch,  530 
Smooth  tongue,  532 
Spasmodic  affections,  641 
Specific  infections,  357 
of  bone,  388 

treatment  of,  407 
of  the  salivary  glands,  499 
Speculum,  oral,  Brophy,  201 
Speech,  cleft  palate,  245 
muscles,     physiological    action    of, 

242 
training,  246 
Sphenopalatine  ganglion,  injection  of 
the,  660 
neuralgia,  649 
Spirocheta  pallida,  365,  471 
Splint,  Angle,  116 

Brown's  modification  of,  308 
Cryer  splint,  119,  123 
Davenport,  121 
Gilmer  posterior  band,  116 
Gunning,  114,  115 

modification  of,  117 
Hammond,  107 
Hayes,  118, 122 
Hullihan,  116 
Kingsley,  90, 115 
Marten,  464 
sectional    metal    jacket    and    wire 

splint.  120 
Tigerstedt,  108 
Splints,  dental,  107 
varieties  of,  114 
Sponges,  205 
Stab  wounds,  65 

Staphylococcus  albus  in  wounds,  70 
Stenson's  duct,  25 
Sterilization  of  dressings,  44 
of  instruments,  44 
of  rubber  gloves,  44 
of  sutures,  45 
Stimson  on  dislocation  of  the  lower 

jaw,  149 
Stomatocace,  360 


Stomatitis,  349 

acute  catarrhal,  249 
aphthous,  352 
chronic,  350 

ulcerative,  360 
exudative,  350 
gonorrheal,  358 
herpes,  350 
mercurial,  353 
mucolofibrinous,  352 
phlegmonous,  416 
Stricture  of  the  pharynx,  615 
Styptic,  blood  transfusion  as  a,  48 
Sublingual  gland,  anatomy  of  the,  24 
invasion  and  excision  of  the,  523 
Subluxation    in    dislocations    of    the 

lower  jaw,  152 
Submaxillary  gland,  anatomy  of  the, 
25 
invasion  and  excision  of  the,  522 
Submucoperiosteal  operation  for  pro- 
trusion of  lower  jaw,  306 
Supernumerary  teeth,  434 

as  cause  of  failure  of  cleft  clos- 
ure, 166 
Suppression  of  urine,  63 
Suppuration,  33 
bacteria  of,  33 
microorganisms  in,  33 
tissue  changes  in,  34 
Surgical    operation    for    malrelations 
of  the  jaws,  indications  for, 
286 
Sutures,  79,  203 

sterilization  of,  45 
Suturing  of  wounds,  71,  79 
Swelling    as    symptom    of    inflamma- 
tion, 29 
Symptoms  of  anterior  dislocation  of 
lower  jaw,  150 
of  antral  infection,  objective,  420 

subjective,  419 
of  inflammation,  29 
of  mechanical      abrasion      of     the 

teeth,  83 
of  ranula,  485 
Syphilis  of  bone,  388 
treatment  of,  408 
of  the  lips,  471 
of  the  mouth,  365 
of  the  salivary  glands,  500 
of  the  tongue,  534 
salvarsan  in,  367 
Syphilitic  fissures  of  the  tongue,  535 


T 


Teeth,  anatomy  of  the,  15 
abrasion,  83 
avulsion  of,  84 

treatment  of,  84 
causes  of  irregular  setting  of  the, 
280 


730 


INDEX. 


Teeth — cont'd 

diagnosis  of  conditions  of  the,  21 
extraction  of,  340-347 
elevators  in, 342 
forceps  in,  341 
individual,  343 
instruments  in,  340 
reasons  for,  340 
temporary,  343 
fracture  of  the,  85 
treatment  of,  85 
Hutchinson,  16 
impacted,  345 

after-treatment  of,  347 
removal  of,  347 
treatment  of,  346 
indications  for,'  346 
implantation  of,  84 
infections  of  the,  371 
loosening  of,  84 

treatment  of,  84 
mechanical  abrasion  of  the,  83 
symptoms  of,  83 
treatment  of,  83 
relation  of  alveolar  cleft  to,  160 
Albrecht's  theory  of,  162 
Ferguson's  theory  of,  161 
Kolliker's  theory  of,  162 
Warnekros'  theory  of,  161 
supernumerary,  434 

as  cause  of  failure  of  cleft  clos- 
ure, 166 
transplantation  of,  84 
Temporal  artery,  construction  of,  630 

ligation  of,  630 
Temporomandibular    joint,    anatomy 
of,  21 
diseases  of  the,  313 
treatment  of,  313 
Tenaculum,  202 

Teratomata  of  the  pharynx,  619 
Tertiary  plaques  of  the  tongue,  535 
Tetanus,  72 

antitoxin,  72 
Thrush,  367 

Thyroglossal  tract,  cysts  of  the,  544 
near  the  foramen  cecum,  544 
perihyoid,  545 
treatment  of,  546 
tumors  of  the,  544 

near  the  foramen  cecum,  544 
perihyoid,  545 
treatment  of,  546 
Thyroid  tumors  and  cysts,  perihyoid, 

545 
Tic  douloureux,  644 
diagnosis  of,  649 
etiology  of,  650 
pathology  of,  650 
symptoms  of,  645 
treatment  of,  650 
facial,  641 


Tic,  facial — cont'd 
prognosis  of,  643 
treatment  of,  643 
Tigerstedt  splint,  108 
Tissue  changes  in  suppuration,  34 
Tongue,  abscess  of  the,  417 

after-treatment     of     operations  on 

the,  590 
anatomy  of  the,  7 
aneurysm  of  the,  539 
black, 532 

cancer  of  the,  551-592 
capillary  nevi  of  the,  539 
carcinoma  of  the,  551-592 
age  in,  552 
chronicity  of,  555 
continuous  growth  of,  556 
death  from,  563 
diagnosis  of,  564 
differential,  565 
microscopical,  567 
differentiation    between    operable 

and  inoperable,  568 
early   clinical   characteristics   of, 

555 
early  diagnosis  of,  553 
early  types  of,  554 
etiology  of,  551 
final  stage  of,  563 
induration  of,  556 
microscopical  appearance  of,  557 
mid-period  of,  558 
clinical  types  of,  562 
general  symptoms  of,  563 
growth  of,  558 
hemorrhage  of,  559 
lymphatic  infection  in,  559 
pain  of,  558 
salivation  in,  559 
ulceration  of,  558 
operation  on,  571 
character  of,  573 
extent  of,  571 
excision    of    tongue    or    laryn- 

gotomy  first  in,  579 
questions  concerning,  572 
removal  of  lymphatics  in,  574 
removal  of  lymph  nodes  in,  574 
time  of,  572 
pain  of,  556 
position  of,  551 
predisposition  to,  551 
prognosis  of,  569 
results  of  operation  on,  570 
treatment  of,  570 
ulceration  in,  556 
cavernous  angioma  of  the,  540 
diagnosis  of,  541 
treatment  of,  541 
chancre  of  the,  534 
congenital  affection,  524 
deformities  of  the,  524 
dyspeptic,  527  '  / 


INDEX. 


731 


Tongue — cont'd 

excision  of  the,  bilateral,  587 
Kocher's  normal,  588 
one-half  of  the  body,  583 
V-shaped,  579 
fibroma  of  the,  544 
fissures  of  the,  525 
geographical,  528 
gumma  of  the,  536 
hairy,  532 

ichthyosis  of  the,  532 
indentations  of  the,  525 
inflammation  of  the,  527 
keloid  of  the,  544 
leucoma  of  the,  529 
leucoplakia,  of  the,  529 
lipoma  of  the,  543 
mucous  patch  of  the,  534 
nodules  of  the,  525 
operation  for  removal  of  the,  580 
anesthetic  in,  581 
bilateral,  587 
excision     of    one-half    of    the 

body  in,  583 
general  preparation  for,  580 
intraoral,  581 
local  preparation  for,  580 
position  of  the  table  in,  581 
V-shaped,  581 
papillomata  of  the,  547 

treatment  of,  548 
psoriasis  of  the,  531 
raw,  527 

resection  of  the,  at  the  root,  Koch- 
er's operation,  589 
sarcoma  of  the,  549 
treatment  of,  550 
smoker's  patch  of  the,  530 
smooth,  532 
syphilis  of  the,  534 
syphilitic  fissures  of  the,  535 
tertiary  plaques  of  the,  535 
-tie,  524 

tuberculosis  of  the,  533 
tuberculous  fissures  of  the,  533 

ulcers  of  the,  533 
tumors  of  the,  537-550 
blood-vessels  of  the,  539 
cartilaginous,  543 
ulcers  of  the,  525 
dentition,  527 
traumatic,  526 
warts  of  the,  547 
treatment  of,  548 
Tonsil  scissors,  170 
Tonsillar  abscess,  611 

treatment  of,  612 
Tonsillitis,  acute,  611 
Tonsils,  tumors  of  the,  619 
Transfusion,  blood,  55 

for  prevention  of  hemorrhage,  48 
intravenous,  53 
saline,  53 


Transfusion,  saline — confd 
selection  of  donor  in,  55 
technique  of,  55 
Transmucoperiosteal     operation     for 
protrusion  of  the  lower  jaw, 
305 
Transplantation,    fiap,    operation    on 
oral  scar  bands  by,  319 
of  bone   or   cartilage   for   obliquity 
of  the  chin,  298 
to    repair   bony    defect    of   lower 
jaw  at  chin,  273 
of  skin-  or  mucus-covered  flaps,  249 
after-treatment  of,  278 
blood  supply  of,  257 
cheek  flaps  in,  252 
forehead  flaps,  252 
neck  flaps  in,  253 
preparation  of  margins  of  the 

defect  in,  250 
preservation    of   the    epithelial 

lining  of  the  mouth  in,  251 
preservation      of     the      motor 

nerve  in,  251 
shoulder  and  chest  flaps  in,  256 
of  teeth,  84 
Treatment  of  acute  adenitis,  409 
antral  infection,  421 
cellulitis,  412 
of  adhesions  of  the  velum,  fauces, 

and  pharyngeal  wall,  616 
of  affections  of  the  facial  nerve,  638 
of  alveolar  abscess,  392 
of  avulsion  of  the  teeth,  84 
of  branchial  fistula,  609 
of  burns,  78 
of  cancrum  oris,  356 
of  carcinoma,  442 

of  the    cervical    lymphatics,    sec- 
ondary, 603 
of  the  lip,  475 
of  the  tongue,  570 
x-ray  in,  443 
of     cavernous     angioma      of      the 

tongue,  541 
of  chronic  adenitis,  415 
antral  infection,  421,  422 
bone  abscess,  399 

by  obliteration  of  cavity  with 

bone  plombe,  401 
by  obliteration  of  cavity  with 

living  tissue,  403 
with  Beck's  bismuth  paste,  401 
cellulitis,  416 
of  cysts  of  the  antrum,  426 

of  the  thyroglossal  tract,  546 
of  depressed  bridge,  330 
of  diseases  of  the  temporomandib- 
ular joint,  313 
of  dislocation  of  the  lower  jaw,  150 
of  effects  of  hemorrhage,  52 
of  epulis,  428 
of  facial  tic,  643 


INDEX. 


Treatment — con  t'd 

of  fracture  of  the  alveolar  process, 
85 
of  the  lower  jaw,  99 

complicated    by    loss    of    bone, 

135 
feeding  during,  128 
individual,  131 
of  the  nose,  328 
of  the  teeth,  85 
of  the  upper  jaw,  87 
of  gangrene,  355 
of  gas  gangrene,  73 
of  gunshot    fractures    of    the    jaw- 
bone, 136 
of  impacted  teeth,  346 
indications  for,  346 
of  infections,  35 
by  antitoxins,  37 
by  cold,  36 
by  heat,  36 
by  hyperemia,  36 
by  surgery,  35 
of  bone,  specific,  407 
of  the  jaw-bones,  392 
of  the  peridental  tissues,  392 
of  the    salivary    glands,    second- 
ary, 494 
of  the  teeth, 392 
of  inflammations,  35 
of  loosening  of  the  teeth,  84 
of  lymphangiomatous       macroglos- 

sia,  538 
of  malrelations  of  the  jaws,  ortho- 
dontia in,  286 
of  mechanical      abrasion      of     the 

teeth,  83 
of  nasopharyngeal  fibroma,  621 

polypus,  621 
of  necrosis,  396 

by    removal    of   the    sequestrum, 
398 
of  noma,  355 
of  obstruction  of  the  ducts  of  the 

salivary  glands,  500 
of  odontoma,  434 

of  oral  scar  bands,  operative,  318 
of  palate  adenoma,  621 
of  papillomata  of  the  tongue,  548 
of  paralytic  affections,  635 
of  pericementitis,  405 
of  ranula,  486 

of  retromaxillary  fibromata,  451 
of  retropharyngeal  abscess,  614 
of  salivary  calculi,  504 
of  salivary  fistula,  507 
of  sarcoma,  437 
of  the  tongue,  550 
starvation,  438 
of  shock, 38 

of  sinus  leading  to  a  dermoid,  490 
of  slough,  355 
of  syphilis  of  bone,  408 


Treatment — cont'd 
of  tic  douloureux,  650 
of  tonsillar  abscess,  612 
of  tuberculosis  of  bone,  407 
of  tuberculous  adenitis,  594 
of  tumors  of  the  antrum,  426 

of  the  thyroglossal  tract,  546 
of  warts  of  the  tongue,  548 
of  wounds,  76 

involving  bone,  698 

of  soft  tissues,  697 
Trench  mouth,  362 

Trifacial  nerve,  affections  of  the,  636 
Tuberculosis  of  bone,  389 

treatment  of,  407 
of  the  lips,  470 
of  the  mouth,  363 
of  the  salivary  glands,  499 
of  the  tongue,  533 
Tuberculous  adenitis,  593 

diagnosis  of,  594 

radical  operation  for,  597 
results  of,  602 

symptoms  and  course  of,  593 

treatment  of,  594 
diseases  of  the  cervical  lymphatics, 

593 
fissures  of  the  tongue,  533 
ulcers  of  the  tongue,  533 
Tumors,  40 

as  cause  of  failure  of  cleft  closure, 

166 
benign,  40 
classification  of,  40 
examination  of,  2 
malignant,  40 
multiloclilar  cystic,  439 
of  bone,  391 
of  the  antrum,  426 

treatment  of,  426 
of  the  jaw-bones,  427 
of  the  lip,  468 
of  the  mouth,  427 

of  the  floor,  484 
benign, 491 
malignant,  491 
of  the  pharynx,  619 

benign, 620 

malignant,  623 

vascular,  620 
of  the  salivary  glands,  513 

benign, 513 

epithelial,  516 

inflammatory,  498 

mixed,  513 
of  the  thyroglossal  tract,  544 

near  the  foramen  cecum,  544 

perihyoid,  545 

treatment  of,  546 
of  the  tongue,  537-550 

cartilaginous,  543 


INDEX. 


733 


Tumors  of  ton'gue — cont'd 
of  blood  vessels,  539 
of  the  tonsils,  619 
of  the  velum,  619 
retromaxillary,  450 

U 

Ulceration     of     carcinoma     of     the 

tongue,  556,  558 
Ulcers,  definition  of,  32 
examination  of,  32 
of  the  tongue,  525 
dentition,  527 
traumatic,  526 
tuberculous,  533 
Union,    delayed,    in   fractures   of   the 
lower  jaw,  136 
time  required   for,  in  fractures  of 
the  lower  jaw,  135 
Unreduced  dislocations,  152 
Urine,  suppression  of,  63 


V 


V-shaped    operation    for    removal    of 

the  tongue,  581 
Vaccines,  autogenous,  method  of  pre- 
paring and  administering,  37 
combined,  38 
standardized,  39 
stock, 37 

unstandardized,  39 
Vallecula,  607 
Varicella,  357 
Variola,  357 

Vascular  tumors  of  the  pharynx,  620 
Vasoconstrictor  drugs  in  hemorrhage, 

51 
Veins,  bleeding,  49 
Vela,  artificial,  244 

Velum,  fauces,    and   pharyngeal  wall, 
adhesions  of,  615 
prognosis  of,  618 
treatment  of,  616 
tumors  of  the,  619 
Venous  angioma,  522 
Verrucula,  532 
Vestibule  of  the  mouth,  anatomy  of, 

19 
Vincent's  angina,  361 
Von  Pirquet  reaction,  364 

W 

War    injuries,    limitation    of    move- 
ments of  jaw  following,  315 
wounds,  treatment  of,  697 
Warnekros  obturator,  244 
theory  of  relation  of  alveolar  cleft 
to  teeth,  161 
Warts  of  the  lips,  473 
of  the  tongue,  546 
treatment  of,  548 


Wharton's  duct,  cysts  of,  486 
White   operation   for  tuberculous   in- 
fection  of  the  cervical   lym- 
phatics, 597 
Whitehead  gag,  201 

operation      for     excision      of     the 
tongue,  587 
Wine  spots,  472 

Wiring    bone    for    fracture    of    lower 
jaw,  104 
jaw  at  or  in  front  of  second  molar, 

106 
of  the  lower  to  the  upper  jaw,  100 
Wounds,  65 
bacteria  in,  70 
closed  wounds,  68 
contused,  65 
drainage  of,  71 
extent  and  character  of,  65 
gas  bacillus  infection,  73 
granulations  in,  74 
gunshot,  66 

explosive  shells,  67 
hand  grenades,  67 
infection,  67 
machine  gun,  66 
shrapnel,  66 
healing  of,  73 

by  first  intention,  74 
in  salivary  glands,  505 
incised,  65 
infection  of,  69 
location  of  foreign  body  in,  by  x- 

ray,  69 
plastic  operations  in,  76 
possible   presence   of   foreign   body 

in,  68 
probability  of  sepsis  in,  69 
puncture,  65 
scars  after,  74 
stab, 65 

Staphylococcus  albus  in,  70 
suturing  of,  71,  76 
tetanus  in,  72 
treatment  of,  76 
war,  treatment  of,  697 
Wright,  method  of  determining  num- 
ber of  bacteria,  38 
Wyeth,  method  of  obliterating  angio- 
mata,  472 


X 


X-ray  burns,  78 

for     locating     foreign     bodies     in 

wounds,  69 
in  antral  infection,  420 
in  diagnosis     of     fracture     of    the 

lower  jaw,  98 
in  treatment   of  carcinoma  of  the 
tongue,  570 
of  keloid,  544 


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